MISSOURI
Official Publication of the Missouri Academy of Family Physicians
Family Physician
APR − JUN 2012 Volume 31, Issue 2
Show Me Family Medicine
in the State Capitol
Resident Grandrounds Brian Gillenwater, DO pg. 12
Tar Wars Presenters Making a Difference pg. 10
pg. 7
Annual Scientific Assembly Schedule of Events pg. 20
contents MAFP
Executive Commission Board Chair Keith Ratcliff, MD (Washington) President Todd Shaffer, MD, MBA (Lee’s Summit) President-elect Kate Lichtenberg, DO, MPH (Kirkwood) Vice President Bill Fish, MD (Liberty) Secretary/Treasurer David Kapp, MD (Perryville) Board of Directors District 1 Director: Dana Granberg, MD Alternate: Jennifer Moretina, MD District 2 Director: Lisa Mayes, DO Alternate: Vacant District 3 Director: Jeff Suzewits, DO Director: F. David Schneider, MD Alternate: Caroline Rudnick, MD District 4 Director: Kelly Bain, MD Alternate: Jennifer Stearnes-Rosas, MD District 5 Director: Peter Koopman, MD Director: Katherine Friedebach, MD Alternate: James Stevermer, MD, MSPH District 6 Director: Jamie Ulbrich, MD Alternate: Vacant District 7 Director: Daniel Purdom, MD Director: Kathleen Eubanks-Meng, DO Alternate: George Harris, MD, MS District 8 Director: Mark Woods, MD Director: Tracy Godfrey, MD Alternate: Paul Stortz, MD District 9 Director: John Paulson, DO, PhD Alternate: Vacant District 10 Director: Mark Schabbing, MD Alternate: Steven Douglas, MD At-large Director: Robert Schneider, DO Resident Directors Mimi Moon-Propst, MD Suzan Lewis, DO (Alternate) Student Directors Aaron Meyer David Kramer (Alternate) AAFP Delegates Bruce Preston, MD Larry Rues, MD Dave Campbell, MD (Alternate) Darryl Nelson, MD (Alternate) MAFP staff Executive Director Jennifer Bauer Education & Finance Director Nancy Griffin Managing Editor/Member Services Laurie Bernskoetter 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
Mark Your
Calendars 64th Annual Scientific Assembly Resort at Port Arrowhead Lake Ozark, MO June 22 - 24, 2012 20th Annual Fall Conference & SAM Working Group Big Cedar Lodge Ridgedale, MO November 9-11, 2012
20
2012 Annual Scientific Assembly Schedule of Events & Registration Form
Inside this issue George Harris, MD, MS, FAAFP
16 2011-2012 Mercy Family Medicine Residency
5
President's Perspective
17 ALSO Provider Course
Todd Shaffer, MD, MBA, FAAFP
18 ABFM MC-FP Update
6
Will You Be Ready in 3?
20 ASA Schedule of Events
7
2nd Annual Advocacy Day
8
Help Desk Answers
9
4
Member Services
Kate Lichtenberg, DO, MPH, FAAFP
23 ASA Registration Form
Advertisements
Resident Case Studies
2
Cox Health
Rx Outreach Program
6 PPIA
Ed Weisbart, MD, CPE, FAAFP
9
Bristol Manor
10 Tar Wars® Presenters
14 Maxim Physician Resources
11 Update from Multi-State Kate Lichtenberg, DO, MPH, FAAFP
14 SSM Medical Group
12 Resident Grandrounds Brian Gillenwater, DO
18 United Allergy Labs
15 Delta Exchange/TransforMED
14 Help Desk Answers Resident Case Studies
19 National Dairy Council
15 Tobacco Cessation Project
24 Missouri Professionals Mutual
22 ProAssurance
Missouri Family Physician April - June 2012 3
MAFP member services
Member Services Update
George D. Harris, MD, MS, FAAFP MAFP Member Services Commission Co-Chair
M
y focus for this issue is going to cover three areas: the legislative session and our Advocacy Day; residency education and the residency match; and disaster preparedness.
We had a very successful Legislative Advocacy Day on February 28th with good participation of our officers and membership. Some similar topics continue to be discussed such as the Nurse Independent Practice. However, some recent bills include prescription monitoring, volunteer health services, prompt credentialing and workplace safety to name a few. Please check out the Advocacy tab on our website at www.moafp.org for more information on all of the bills tracked and monitored. The education of our medical students and residents must continue to be proactive and on the forefront of the state and local budgets. We need to be able to provide an adequate number of family physicians in the workforce to improve patient access and overall care.
of the SOAP was a collaborative effort that included input from the NRMP, the Association of American Medical Colleges, program directors, resident physicians and affiliated organizations. Hopefully, it has created an easier and more efficient process for all involved. More information can be found on the AAFP website. With more disasters taking place throughout the state and nationally, more groups and facilities are implementing a disaster preparedness plan. Please work with your local communities and hospitals to insure your patients and their families are safe. We have a special section in the journal this month on this topic. Lastly, for our family physician academy members, we continue to identify topics of interest and provide effective, accessible continuing medical education in various formats to ensure life-long learning. We, on the membership commission, hope you are enjoying the changes we have made in the
journal, including the articles on medical topics of interest for your practice. I encourage you to attend our annual meeting this June (June 22-24 at the Resort at Port Arrowhead, Lake Ozark). Some of the topics will include: disaster preparedness and response, vaccine coverage among at-risk adults, and practicechanging updates from the medical literature. We hope you will join us. It is a time for life-long learning, but also for meeting colleagues and sharing ideas and concerns. Also, it is a venue to be more involved in organized medicine and the protection and promotion of our specialty. Help us to educate our patients and members. Let us know how we can meet your needs and prepare you to care for your patients more efficiently and proficiently. We appreciate each of you and thank you for all you do
We continue to promote medical student and resident involvement in our academy. We are fortunate to have several residency programs identify residents who have had interesting and challenging medical cases to present them to our journal for publication. We encourage more residents to consider submitting an article or case presentation. The National Resident Matching Program (NRMP) Match Week occurred March 1216. A new system--the Supplemental Offer and Acceptance Program (SOAP)--kicks in for the first time this year. The SOAP, replaced the former “Scramble� process and consists of eight offer rounds. Creation 4
Missouri Family Physician April - June 2012
Enjoying Match Day ceremonies are three of the four students from the University of Missouri-Kansas City School of Medicine who matched to family medicine. Pictured left to right: Ruth Pitts, Allison Klapetzky and Dylan Werth shown with their professor, George Harris, MD (far right). Not pictured is Kenneth Tan of Columbia, MO who matched to the University of Missouri-Columbia Family Medicine Residency. Photo courtesy of AAFP News Now
president's perspective MAFP
President's Perspective
Todd Shaffer, MD, MBA, FAAFP MAFP President
I
n early March, I was part of an AFMRD (Association of Family Medicine Residency Directors) board meeting at the AAFP headquarters in Kansas City and was able to participate in a great presentation by the AAFP EVP Doug Henley, MD on “The State of the Family.” He made a lot of great points in his presentation and I wanted to share some of those key points with you with his permission. This information is about the positive things happening in Family Medicine and how the future looks even brighter. There are three main sections: AAFP Strategic Priorities, Current AAFP Issues, and Membership Good News.
AAFP Strategic Priorities: The Future of Family Medicine Project (completed in 2004) told us that “Unless there are changes in the broader health care system and within the specialty, the position of family medicine in the United States may be untenable in a 10-20 year time frame, and this would be detrimental to the health of the American public.” Since that time, we have seen the Affordable Health Care Act that places movements to a system much more favorable to Family Medicine. The Patient Centered Medical Home model is all about practice redesign and getting to a newer and better model of care for Family Medicine. HITECH reimbursement for EMRs, policy makers, public, and media with sustained attention to primary care with concerns about payment and workforce. Consumer Primary Care Initiative (CPCI), WellPoint, Aetna, Cigna, and United have all made recent announcements about payment reform benefiting primary care physicians with PCMH certified practices.
How do we know we are making it? It might be that the President of the United States says the words “family doctor” unscripted: June 8, 2010, Town Hall with Seniors: “It used to be that most of us had a family doctor; you would consult with that family doctor; they knew your history, they knew your family, they knew your children, they helped deliver babies. And as a consequence, what happened was, is that everybody got regular checkups and could anticipate a lot of the problems that are out there . . . how do we get more primary physicians, number one; and number two, how do we give them more power so that they are the hub around which a patientcentered medical system exists, right?” There are present leaders in Family Medicine in prominent positions including HRSA, AHRQ, RWJ Policy Fellows, Surgeon General, and COGME adding to the government relations work of the AAFP, FamMedPAC and state chapters. While all of this is supported by very good data showing the greater amount primary care is in a population, you have increasing quality and decreasing cost per capita. Payment reform is a real thing and is already in place for many primary care physicians. Current AAFP Issues: The AFFP will continue to work on the SGR fix, and Payment Reform to provide blended payments of capitation and fee for service that will capture our ability to care for our patients. Consumer research is underway exploring perceptions and preferences about Family Practitioners and Nurse Practitioners.
Residency Redesign for training physicians to work in PCMH practices is happening! One of every four medical students in the U.S. is a member of the AAFP (now over 19,000 students)! The AAFP is also working closely with public health items like social determinates of health since this has the majority of effect on the healthcare of the population. Things being looked at are: education, poverty, social policy, agriculture, and environmental policies that affect all people. Membership Good News: As we have seen with the MAFP chapter, our numbers continue to grow. The AAFP now has over 102,611 members with 64,724 active, 10,650 residents and 19,000 students. The family is growing and stakeholders are listening. There may continue to be a shortage of primary care providers with present predictions. However, more are opting to enter Family Medicine and rewards for cost effective high quality outcomes will be rewarded in the future models of PCMH delivered care. Isn’t it a great time to be a family doctor? There were a lot more statistics and great graphs showing growth and expectations forecast that accentuated what I have written here in Dr Henley’s presentation. If you would like a copy of the presentation, please contact the MAFP office at (573) 635-0830 or email: office@mo-afp.org
Medical Education is a focus for both residencies and medical students. Missouri Family Physician April - June 2012 5
MAFP Disaster Preparedness
Will you be ready in 3? Kate Lichtenberg, DO, MPH, FAAFP MAFP President-Elect Member Services Commission Co-Chair
L
ast fall, MAFP was invited by the Missouri Department of Health and Senior Services to participate in disaster planning and recovery. There was much focus on how to deliver services post-disaster. However, a first step for all of us as physicians is to have a personal preparedness plan. The Missouri Department of Health and Senior Services has published a handbook to help plan for emergencies in 3 steps. The first step is to create a plan for yourself, your family, and your business (practice). The second step is to prepare a
kit for your home, car, and work, and the third step is to listen for information about what to do and where to go during an actual emergency. How will you find your family members if you are not all together when a disaster strikes? What will you do if you have children in school? If you do, do you know where they will be evacuated to in the event of an emergency? Do you have a pet? What supplies to you have on hand and what supplies do you need to have? If you don’t have an emergency kit, how long would it take you to pull together
Check out the PPIA difference.
Professional liability insurance for Missouri physicians 6
Missouri Family Physician April - June 2012
everything you would need? Order your Family Safety Guide for you and your patients by visiting www.dhss. mo.gov. Look for "Ready in 3" included in the right navigation bar. You will be able to take care of your patients if you know your family is prepared and cared for. Through the rest of this year, we will provide you additional information on preparing your practice for disasters and how you can get involved in the medical response team here in Missouri
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advocacy day MAFP
2nd Annual Advocacy Day On February 28, 2012, all participating physicians and those advocating for issues facing family medicine brought their experiences and enthusiasm with them to the State Capitol. MAFP staff scheduled appointments with legislators who had constituents attending Advocacy Day. Attendees shared MAFP's priority issues and stances on pending legislation with their legislators. MAFP distributed spray hand sanitizers to the legislative offices which were personalized with the MAFP logo in the shape of a doctor’s white coat. Coincidentally, there happened to be a hearing where MAFP testified and Keith Ratcliff, MD represented MAFP.
It has been a very busy legislative session for family medicine issues. Both the Senate and House versions of the APRN Independent Practice Legislation have been heard by committees. MAFP would like to thank Arthur Freeland, MD, MAFP Advocacy Chair, and Pat Strader, MAFP Government Consultant, for their efforts in organizing MAFP’s issues and viewpoints. MAFP would also like to recognize MAFP members who took time away from their schedules to attend the hearings and volunteered to testify on the pending nursing legislation. Members include: Dave Barbe, MD; Arthur Freeland, MD; Tess Garcia, MD; Nina Kiekhaefer,
2012 Participants Kelly Bain, MD (New Haven) Catie Benbow, DO (Springfield) Kyra Cass, MD (St. Louis) Steven Douglas, MD (East Prairie) Bill Fish, MD (Liberty) Lainie Franklin (Lee's Summit) Arthur Freeland, MD (Kirksville) Katherine Friedebach, MD (Jefferson City) Tracy Godfrey, MD (Joplin) Dana Granberg, MD (Kansas City) Grant Hoekzema, MD (St. Louis) David Kapp, MD (Perryville) Peter Koopman, MD (Columbia) David Kramer (St. Louis) Suzan Lewis, DO (Grandview) Kate Lichtenberg, DO (Kirkwood) Aaron Meyer (St. Louis) David Miller, MD (Wildwood) Stephanie Pendergrass, MD (Springfield) Shelly Phinney (Lee's Summit) Donald Potts, MD (Independence) Daniel Purdom, MD (Independence) Keith Ratcliff, MD (Washington) Caroline Rudnick, MD (St. Louis) Mark Schabbing, MD (Perryville) F. David Schneider, MD (St. Louis) Robert Schneider, MD (Kirksville) Todd Shaffer, MD (Lee's Summit) Jamie Ulbrich, MD (Marshall) Jonathan Wada, MD (Kansas City) Amy Williams, MD (Columbia)
MD: and Mike Wulfers, MD. MAFP would also like to personally thank the following dedicated advocates of family medicine (listed below) who took time away from their busy schedules to visit the State Capitol on February 28.
Participants are pictured in the photo on the left visiting with Governor Jeremiah "Jay" Nixon about family medicine issues. Pictured above, participants visit with Governor Nixon's Policy Director, Jeff Harris.
What is the MAFP PAC? MAFP PAC is the state political action committee of the Missouri Academy of Family Physicians. MAFP PAC is a special organization set up to collect contributions from a large number of people, pool those funds and make contributions to state election campaigns.
Where does my contribution go? MAFP PAC will make direct contributions to candidates for the Missouri General Assembly (either State House of Representatives or State Senate) and statewide offices. Contribution decisions are made in a nonpartisan way based on candidates' positions, policies and voting
records as they relate to family physicians and our patients. Direct contribution decisions are made by the PAC Committee.
I already pay my dues - isn't that enough? Election laws prohibit the use of membership dues for donations to political candidates. Funds to be used for donations to candidates must be raised separately from membership dues. Voluntary MAFP PAC donations are what will enhance MAFP's clout in the elections and with elected members of the Legislature.
Get Involved! Make your 2012 contribution online at www.mo-afp. org and click on the "Political Action Committee" tab. Missouri Family Physician April - June 2012 7
MAFP help desk answers About HDAs - Resident authors work directly with a physician faculty mentor as “author teams”. Residencies meet RRC requirements, and many programs have developed their faculty into local evidence-based medicine experts!
What is the most effective therapy for vasomotor rhinitis? Evidence-Based Answer Symptoms of vasomotor rhinitis (VR) may be reduced with • Intranasal fluticasone propionate (SOR: A, based on a meta-analysis of RCTs) • Intranasal azelastine (SOR: B, based on one RCT) • Intranasal ipratropium bromide (SOR: B, based on one RCT) • Acupuncture (SOR: C, based on one low-quality RCT) A meta-analysis was performed of 3 randomized, placebocontrolled trials evaluating use of intranasal fluticasone propionate in 983 adult patients with VR.1 Patients with and without nasal eosinophilia were randomized to 3 groups: 200 mcg fluticasone per nostril daily, 400 mcg fluticasone per nostril daily, and placebo. The primary outcome was change over a 28-day treatment period in total nasal symptom score (TNSS; a 300-point symptom score of the patient’s ratings of nasal obstruction, postnasal drip, and rhinorrhea). The mean change in TNSS was –84 in the 200-mcg group, –82 in the 400-mcg group, and –64 in the placebo group (P<.002 for both treatment groups vs placebo). Two multicenter, randomized placebocontrolled trials with 426 adult patients evaluated the efficacy of intranasal azelastine for VR. Patients were randomized to receive 1.1 mg azelastine per nostril daily or placebo nasal spray for 21 days in 2 parallel groups.2 The primary outcome, change in total VR symptom score (patient report of nasal congestion, postnasal drip, sneezing, and rhinorrhea graded as 0=none to 3=severe during the previous 12 hours), was reduced by 24% and 22% in the azelastine groups, but by only 11% and 12% in the placebo groups (P<.001 and P=.007, respectively). Another RCT evaluated 233 adult patients randomized to ipratropium 0.03% nasal spray 2 sprays per nostril 3 times daily or placebo.3 The primary outcome measures of duration and severity of 8
Missouri Family Physician April - June 2012
March 2012 EBP
rhinorrhea decreased 34% and 30%, respectively, in the ipratropium group compared with 19% and 15% in the placebo group (P<.05 for both comparisons). Finally, a 2009 RCT included 24 adult patients randomized to acupuncture or sham laser for treatment of VR. The primary outcome of change in nasal sickness score (NSS; a 27-point scale assessed by patient response to a questionnaire) was –5.2 points for acupuncture compared with –2.0 points for placebo (P<.01). Limitations included small study size and a significant baseline difference in NSS between groups.4 Kara Mayes, MD Marsha Mertens, MD St. Johns Mercy FMR St. Louis, MO 1. Webb DR, et al. Ann Allergy Asthma Immunol. 2002; 88(4):385–390. [LOE 1a] 2. Banov CH, et al. Ann Allergy Asthma Immunol. 2001; 86(1):28–35. [LOE 1b] 3. Bronsky EA, et al. J Allergy Clin Immunol. 1995; 95(5 pt 2):1117–1122. [LOE 1b] 4. Fleckenstein J, et al. J Altern Complement Med. 2009; 15(4):391–398. [LOE 2b–]
Rx outreach program MAFP
Rx Outreach Program by Ed Weisbart, MD, CPE, FAAFP Rx Outreach Program Chief Medical Officer
F
amily physicians often have patients in desperate situations we don’t even know about. For whatever reason, many patients are reluctant to talk about their financial struggles. But these struggles very much impact our ability to help them.
The worse poverty gets, the more adherence falls with the smallest increase in drug expenditures. For people under the federal poverty level, even $4-8 per month can reduce adherence by as much as 10%.1 Despite this fact, 57% of patients with no insurance coverage never even speak with their physicians about the cost of their medications.2 No matter how brilliant our diagnoses and treatment plans, there is no point in prescribing something our patients will never be able to take.
medications that are not typically included on generic lists area available, even some that are brand name. While it seems to good to be true, it really isn’t. It is real. Rx Outreach was founded with a generous donation, and we have been fortunate to acquire great drug acquisition contracts, and we have no profit layered on top of our costs.
Hundreds of drugs are offered in 40 chronic conditions including diabetes, hypertension, and depression. Many are offered for six-month supplies. Many
1. 2.
It is easy to get started. Give your patient a prescription for one of the drugs on our list for 180 days with one refill (or 90
3.
Moitabai,R and Olfson,M. DataWatch, Aug. 2003 Shrank, W. Journal of General Internal Medicine. 2006 Apr;21(4):334-9 Devine S, Vlahiotis A, Sundar H. J Med Econ. 2010;13(2):203-11.
Your patients deserve the best in
Senior Living.
There are two key strategies to improve medication adherence: make it affordable and make sure your patient has plenty of medication. Adherence improves when medications are dispensed in three to six month quantities.3 Rx Outreach is an independent nonprofit charitable mail order pharmacy that provides affordable medications for people in need. Anyone up to 300% of the federal poverty level ($33,150 for an individual or $69,150 for a family of four) can get access to hundreds of drugs at incredibly low fees. No documentation of income, no pay stubs, and no tax returns are required. If patients self-attest that they meet the financial eligibility guidelines, they are able to easily enroll in the program.
days with 3 refills) and point them to our website (www.rxoutreach.org) to enroll either online, download an application, or for us to mail out an application, and your patients can send it back with the appropriate fee. You can also fax it to 1-800875-6591.
Y
our patients’ care is important to you. It’s also important to us. For more than 20 years, we’ve provided the best in senior living and care to 64 communities throughout Missouri. Sure we have the necessities – safety, comfort and service. But we also add fun, friendship and laughter so our seniors get the most out of life. For more information, see our web sites or call 888-826-0404 or 660-287-2424.
www.bristol-manor.com
www.theessex.net
www.ashburyheights.com
Missouri Family Physician April - June 2012 9 164.29142 REV Missouri Family Physician Ad.indd 1
10/12/11 11:19 AM
MAFP Tar wars presenters
Presenters making a difference in their local schools With the help of local physicians and health care professionals, the Tar Wars速 message is on the move. During the 2011-2012 school year, Glenda Bertz, RN, Public Health Nurse, and Donna Oetting, Health Program Representative, both with the Lafayette County Health Department in Lexington, Missouri, presented to fifthgrade students at Wellington-Napoleon R-IX School District.
Katherine Friedebach, MD, presented to fifth-grade students at Cole R-V Eugene Elementary School on January 13, 2012. Above, students participated in the Tobacco Advertisement activity.
of the health effects of tobacco, the cost of tobacco, and how the tobacco companies try to make it appealing to teenagers. I love the Tar Wars curriculum because it is interactive, and the students have a chance to share the message with other students through the poster contest."
Glenda, who has been presenting Tar Wars for the past four years, stated Katherine Friedebach, MD, a provider "Tobacco use remains the leading "Hopefully we can do some early education with Community Health Center of preventable cause of death and disease to students before they ever try tobacco, Central Missouri located in Jefferson in the United States. Studies show that or before it becomes a habit. Tar Wars is City, presented along with Lindsey almost 90% of adults who have become not only about tobacco education, but the regular smokers began smoking by the program helps children to make good choices" Haslag, RN, BSN, and Nikki Smith, LPN, to fifth-grade students at Cole R-V time they were the age of 18. That is Glenda Bertz, RN Eugene Elementary School on January why Tar Wars is so important. Hopefully 13, 2012. As a frequent presenter, Dr. we can do some early education to Friedebach often seeks out local schools to present to which helps students before they ever try tobacco, or before it becomes a habit. increase participation in the Missouri Tar Wars program. Along Tar Wars is not only about tobacco education, but the program with other local family physicians and community leaders, she helps children to make good choices. We want them to be aware judges the posters submitted to MAFP for the state poster contest. Tar Wars速 was founded in response to a growing, yet preventable, health crisis. Targeting fourth and fifth grade students, this tobacco-free education program and poster contest of the American Academy of Family Physicians adopts an effective and innovative approach to teaching tobacco prevention. In the tobacco-free poster and video competition, children are encouraged to create their own positive message using posters or short videos. One winner from each state is invited to attend the Tar Wars National Conference in Washington, DC. While on site, the children and their families have the opportunity to visit with legislators and advocate for tobacco-free issues and family medicine.
Fifth-grade students at Cole R-V Eugene Elementary School, pictured above, participated in the Straw Breathing activity during a Tar Wars presenation. 10 Missouri Family Physician April - June 2012
You can make a difference in the health of your community by educating as many children as possible about the harmful effects of tobacco use and generating awareness of the deceiving nature of tobacco advertising. You can be a role model in your community and help to encourage children to celebrate, promote, and >>
update from multi-state MAFP
Update from Multi-State Forum by Kate Lichtenberg, DO, MPH, FAAFP In mid-February, Bill Fish, MD and I attended the Multi-State forum in Dallas. Dr. Roland Goertz, Chairman of the AAFP Board, provided an update on what our national academy is doing in Washington, DC. We heard from other states on their legislative issues. Not surprisingly, scope of practice issues are widespread. Work force issues are also a hot topic. Patient centered medical homes were also discussed at length. For our members who are in the midst of this transition, you can log on to Delta Exchange for free with your member ID. See page 15 for more information about Delta Exchange. This can be a valuable resource providing information from experts and practices that have completed the PCMH transition. Best practices from all of the chapters were shared as well. Everything from retaining recent residency graduates to conducting surveys was covered. Advocacy is also a top priority. Some states have a physician at the capitol every day that the legislature is in session. In Kansas, the surgeons joined the family doctors for an advocacy day at the capitol. We hope to incorporate some of these best practices and improve the services we provide to our members. As always, if you have an idea about how we can improve our services for you, please contact our MAFP staff in Jefferson City at (573) 635-0830.
Pictured left to right: Bill Fish, MD, Kate Lichtenberg, DO and Julie Wood, MD.
On a historical note, a few physicians and state chapter executives from six states (AR, KS, LA, NM, OK, and TX) met in Grapevine, Texas to discuss family medicine policy and similar state chapter issues in 1985. Today, Multi-State Forum consists of eleven states (AZ, AR, CA, CO, IA, KS, NE, NM, OK, TX and MO) participating with a few guests from other states. The agenda topics are the same as twenty-five years ago. One interesting fact is that one of the original participants, John M. Casebolt, MD, of Multi-State Forum graduated with his MD from the University of Missouri in 1958 and his father, Milton B. Casebolt, MD, served as MAFP President in 1952. MAFP usually sends at least one chapter officer, the chapter executive, and other interested leaders to this conference.
>> enjoy tobacco-free lives. For additional information, please contact Nancy Griffin at ngriffin@mo-afp.org or visit www.mo-afp.org/
tarwars. An electronic version of the Tar Wars Program Guide for teachers and presenters which provides instructions for implementing the Tar Wars速 program in the classroom is available at www.tarwars.org.
Pictured above: Donna Oetting (far right), Health Program Representative with the Lafayette County Health Department in Lexington, Missouri, is pictured with students from the Wellington-Napoleon R-IX School District who won their school's poster contest. Pictured right: Glenda Bertz, RN, Public Health Nurse with the Lafayette County Health Department, assists Wellington-Napoleon R-IX School District fifth-grade students with the Balloon activity. Missouri Family Physician April - June 2012 11
MAFP resident grandrounds
Heroin Use as an Uncommon Presentation of Acute Compartment Syndrome Brian Gillenwater, DO, PGY-2 Research Family Medicine Residency Program Introduction In the urgent care or emergency setting, maintaining an index of high clinical suspicion and broad differential diagnosis is important when ruling out medical emergencies. Acute compartment syndrome (ACS) requires immediate surgical intervention and, if left untreated, ACS could lead to significant morbidity and mortality. Obtaining an accurate history of present illness, physical exam, and achieving prompt surgical intervention can save life and limb. Below, we offer an unusual case presentation with the diagnosis of ACS. We will discuss pathophysiology, causes, history and physical evaluation, treatment and complications. Case Presentation A 31-year-old Caucasian male with a past medical history significant for hepatitis C and poly-substance abuse was admitted for severe swelling of his left upper extremity. The patient was initially diagnosed with cellulitis. His presentation in the ER was complicated by the fact that the patient had altered mental status and was unable to provide an accurate history to the emergency room physicians. His medical presentation was further complicated by acute end organ damage including acute renal failure and rhabdomyolysis along with his altered mental status. The patient was noted to meet severe sepsis criteria and was subsequently admitted to the ICU for triple antibiotic therapy and aggressive IV fluid resuscitation. Although unknown to us at admission, the patient later admitted to an episode 12 Missouri Family Physician April - June 2012
of intravenous (IV) drug use, just prior to hospitalization which included IV heroin and cocaine. The patient stated he was using drugs throughout the night and subsequently fell asleep in his car, slumped over on his arm rest on his left side. In the morning, the patient woke up with significant pain on the same side of the drug use site and was noted to have increasing muscle weakness on the ipsilateral side. According to the patient’s time table, he did not seek medical attention for approximately 14 hours.
with the diagnosis of ACS.
Pertinent physical exam findings, on admission, included left upper extremity remarkable for swelling, tenderness and induration extending from the elbow to two-thirds of the way down the forearm. Patient also had decreased passive and active range of motion. During passive range of motion testing to both flexion and extension, there was noted increased pain out of proportion to examination. Patient was also noted to have decreased two point tactile discrimination and sensation as well as weakness to hand grip strength. Left ante-cubital puncture marks were noted, corresponding to the history of intravenous drug abuse. Initial laboratory testing revealed: total creatinine kinase 61488 units/L, serum creatinine 3.3 mg/dL, lactic acid 4.0 mmol/L, and white blood count 46.6 K/mm3. Given the patient’s HPI and physical examination findings, concern for ACS was noted. From the ICU, surgery was consulted and the patient underwent immediate bedside medial and volar fasciotomies. Surgical findings, including severe muscular edema without obvious signs of necrosis or sepsis, were consistent
Discussion Acute Compartment Syndrome (ACS) is a condition in which pressure increases within a fascial muscle compartment which encapsulates muscles, nerves, vessels, and tendons. Increasing interstitial pressure in a closed fascial compartment reduces capillary blood flow resulting in microvascular compromise.1,2 This ischemic tissue becomes edematous, leading to further increase in intracompartmental pressure. If left untreated, ACS can lead to devastating loss of function, infection, neurologic deficit, need for amputation, and possibly death.1,2 Irreversible damage and necrosis may occur within three hours of onset.3 Of the upper extremity, the forearm is the most common site for compartment syndrome.2
Throughout the 20-day hospital course, the patient was followed by surgeons until final closure of compartments at post-operative day 18. During the hospitalization, the patient’s medical course was complicated by severe acute renal failure requiring hemodialysis, rhabdomyolysis, and clostridium difficulis colitis. At the time of discharge, the patient did not have full range of motion or sensation in the affected left forearm.
Pearse and Nanchahal3 report that the majority of ACS’s occur as a direct result of trauma. Other possible causes include soft tissue injury, limb compression, and prolonged limb positioning, either from drug overdose or lengthy surgical procedures.2 >>
resident grandrounds MAFP >>
Several retrospective reviews have been conducted assessing the incidence and causes of ACS.4-6 One study, performed by McQueen et al.4, collected data from an orthopedic trauma unit in Scotland from 1988 to 1995 to identify those patients at risk for ACS. The trauma unit served a population of 650,000, indicating a high rate of capture. The study included 164 patients, 149 men and 15 women, diagnosed with ACS during that time. The average annual incidence was 7.3 per 100,000 for men and 0.7 per 100,000 for women. The data collected stated that the most common etiologies producing ACS were fractures (113 patients), specifically to the diaphysis of the tibia (59 patients) and distal radius fractures (16 patients). The most common modality was from a trauma related injury (126 patients), while other etiologies included soft tissue injury without fractures (38 patients). Modes for soft tissue injuries included crush injuries, direct blows, and those patients taking anticoagulants or with bleeding disorders. Of those with soft tissue injuries, the most commonly affected compartments were the leg (21 patients) followed by the forearm (9 patients), quadriceps (5 patients), foot (2 patients), and 1 patient with compartment syndrome in the hand. Two patients with ACS from soft tissue injuries were reported as a direct consequence of IV drug abuse. Cascio et al.5 found similar results at John Hopkins University academic center. This retrospective study identified 38 patients undergoing emergent fasciotomy for ACS between 1992 and 2002. Again, the most common injury was from a tibial fracture. This study reported 4 cases related to prolonged positioning, two due to surgery and two due to drug overdose. It has been well documented that the most common cause of ACS is traumatic injury. Less common etiologies include prolonged positioning and IV drug abuse, such as our patient that presented after being in a hunched position on his left forearm following IV drug use. Buckland et al.6, evaluated upper limb mortality as a direct consequence of IV drug abuse using
a retrospective study over a two year period ending in 2006 in Melbourne, Australia. Thirty-six patients were admitted with complications relating to IV drug abuse. Twenty-nine of those patients presented secondary to infective etiology, five to arterial injection, one to compartment syndrome, and one to soft tissue necrosis. Fifteen of these patients were noted to have intravenous heroin abuse. According to this study, ~81% of IV drug users admitted to the hospital were secondary to infectious etiology, while only one patient presented secondary to atraumatic rhabdomlyosis complicating ACS. Multiple similar studies evaluated IV drug use demonstrating it as an uncommon cause and presentation of ACS, complicated by severe rhabdomyolysis.7,8 Maintaining a high index of suspicion along with pertinent HPI including history of limb trauma (traumatic or nontraumatic) is essential in diagnosing acute compartment syndrome. Classically, the 6-Pâ&#x20AC;&#x2122;s of pain, pressure, pallor, pulselessness, paralysis, and paresthesia are diagnostic of ACS.1,9 Pain that persists despite appropriate analgesia appearing out of proportion to injury, including pain with passive flexion of involved compartments, are the earliest indicators for compartment syndrome.1,3,9 Diminished sensory changes, including 2 point tactile discrimination, and a tense, swollen compartment with muscle weakness could also be noted. Although pallor and pulselessness are listed, Olson9 suggests that arterial inflow is an uncommon finding. Each symptom above indicates possible involvement and damage to tissues including muscles, nerves and vascular supply. ACS is typically diagnosed from history and physical alone, but intracompartmental pressure (ICP) measurements may be obtained to make a definitive diagnosis.10 Garner10 suggests that no consensus for monitoring intracompartmental pressures exist, but using thresholds of 40mm Hg for observation and 50 mm Hg for immediate decompression is reasonable without many adverse effects. In our case, we did not
monitor ICP, but it may be warranted if index of suspicion is high. As previously noted, definitive diagnosis is early detection. Time from initial onset is the most important predictor of outcome.4,11 Matave, et al.12 demonstrated that treatment greater than 8 hours in the canine model leads to irreversible damage. Pearse and Oslon3,9 suggest that delaying treatment 35 hours has been associated with concomitant severe infection, amputation, and death. Inadequate therapy leads to muscle ischemia, rhabdomyolysis, and renal insufficiency.11 Conclusion Acute compartment syndrome is a potentially devastating medical emergency requiring immediate surgical intervention. Above, we demonstrated that ACS has many causes, most commonly traumatic and most notably occurring in young men due to tibial fracture. This case focuses on the uncommon presentation of heroin IV drug abuse as one possible etiology of ACS. Recognizing the physical signs and symptoms of ACS, even in atypical presentations, is essential to preventing mortality and morbidity. References 1. Prasarn M, Ouellette E. Acute Compartment Syndrome of the Upper Extremity. Journal of the American Academy Orthopaedic Surgeons 2011; 19 (1): 49-58. 2. Botte M, Gelberman R. Acute Compartment Syndrome of the Forearm. Hand Clinics 1998; 14 (3): 391-403. 3. Pearse M, Nanchahal J. Acute Compartment syndrome: reducing the risk. The AvMA Medical &Legal Journal 2008; 14 (3): 114-18. 4. McQueen M, Gaston P, Court-Brown C. Acute Compartment Syndrome: Who is at Risk? Journal of Bone and Joint Surgery (British) 2000; 82 (2): 200203. 5. Cascio B, Wilckens J, et al. continued on page 15 Missouri Family Physician April - June 2012 13
MAFP help desk answers Does the use of bronchodilators in mechanically ventilated patients without a prior history of March 2012 EBP obstructive lung disease improve patient outcomes? Evidence-Based Answer Bronchodilators do not alter important outcomes in mechanically ventilated patients without prior obstructive lung disease. (SOR: B, based on an RCT and prospective cohort study.) A 2007 prospective cohort study evaluated the effect of bronchodilators for 6 months in 206 mechanically ventilated patients.1 Patients with obstructive lung disease were excluded. Overall, 74 patients received bronchodilators (albuterol and ipratropium bromide) without a clear indication for them. Patients treated with bronchodilators without indications were found to have a greater degree of hypoxemia with lower mean PaO2/FiO2 ratio (188 vs 238 mmHg, P=.004); they were also more likely to contract pneumonia during the intensive care unit stay (53% vs 33%; P=.007). In addition, there was a mean extra cost of $449.35 for each patient who received bronchodilator therapy. No statistically significant difference was noted in the incidence of ventilator-associated pneumonia, tracheostomy, or mortality.1 In another study, 282 hospitalized patients with acute
Full, Part-time, & Locum Tenens Physician Openings in Missouri Maxim Physician Resources (MPR) specializes in placing qualified physicians, including Primary Care, ER, Psychiatry, Inpatient, etc., in rewarding locum tenens assignments nationwide. MPR currently has several opportunities available in Missouri. Whether you are a physician seeking a new opportunity or looking for supplemental assignments, we can help.
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Phone: 888-800-1853 www.maximphysicians.com 14 Missouri Family Physician April - June 2012
lung injury and without prior pulmonary disease were randomized to receive an aerosolized β2 agonist (every 4 hours for up to 10 days) or placebo when on mechanical ventilation.2 The primary outcome studied was the number of ventilatorfree days (VFDs). No significant difference wasw noted in VFDs between the albuterol and placebo groups (14 vs 17 VFDs; 95% CI, -4.7 to 0.3; P=.087). The study was discontinued early due to treatment futility based on preset parameters. Mortality rates prior to discharge were not significantly different between the albuterol and placebo pool (23% vs 18%; 95% CI, -4.0 to 15; P=.30).2 Chad Reid, MD Gazala Parvin, MD Research FMR Kansas City, MO 1. 2.
Chang LH, et al. Respir Care. 2007; 52(2):154â&#x20AC;&#x201C;158. [LOE 2b] National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Am J Respir Crit Care Med. 2011; 184(5):561-568. [LOE 1b]
tobacco cessation project MAFP
Resident Grandrounds continued from page 13
6.
7.
8.
9.
Documentation of Acute Compartment Syndrome at an Academic Health-Care Center. Journal of Bone and Joint Surgery 2005; 87 (2): 346-350. Buckland A, Barton R, McCombe D. Upper Limb Morbidity as a Direct Consequence of Intravenous Drug Abuse. Hand Surgery 2008; 13 (2): 73-78. Sahni V, Dheeraj G, et al. Unusual complications of heroin abuse: Transverse myelitis, rhabdomyolysis, compartment syndrome, and ARF. Clinical Toxicology 2008; 46: 153-155. Oâ&#x20AC;&#x2122;Connor G, McMahon G. Complications of heroin abuse. European Journal of Emergency Medicine 2008; 15 (2): 104-6. Olson S, Glasgow R. Acute compartment syndrome in lower extremity musculoskeletal trauma.
Journal of the American Academy Orthopaedic Surgeons 2005; 13 (7): 436-44. 10. Garner A, Handa A. Screening Tools in the Diagnosis of Acute Compartment Syndrome. Angiology 2010; 61 (5): 475-481. 11. Heemskerk J, Kitslaar P. Acute Compartment Syndrome of the Lower Leg: Retrospective Study on Prevalence, Technique, and Outcome of Fasciotomies. Journal of World Surgery 2003; 27: 744-47. 12. Matave MJ, Whitesides TE Jr, Seiler JG III, Hewan-Lowe K, Hutton WC. Determination of the compartment pressure threshold of muscle ischemia in a canine model. Journal of Trauma 1994; 37 (1): 50-58.
Office Champions Tobacco Cessation National Dissemination Project The AAFP is now recruiting 50 family medicine offices for the Office Champions Tobacco Cessation National Dissemination Project. This project will provide practical strategies through an online training module, live teleconferences and assorted materials for making system changes in medical practices to improve tobacco cessation activities. To apply, please visit www.aafp.org and
1 click on Clinical & Research tab 2 click on Public Health tab
3 click on Ask and Act Tobacco Cessation Program
4 click on Office Champions Project on left navigation menu
5 complete the application and return it as directed by MAY 8, 2012.
For more information, contact Sandy Sheehy at ssheehy@aafp.org or 800-274-2237 x 3141.
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MAFP mercy family medicine In the Jan-Mar 2012 issue of the Missouri Family Physician, the 2011-2012 Mercy Family Medicine Residency roster was inadvertantly omitted. Please see the current residency roster below.
Alison Ball, DO PGY-1 Kirksville College of Osteopathic Medicine
Joshua Behlmann, DO PGY-1 Kirksville College of Osteopathic Medicine
Tina Bosslet, MD PGY-3 St. Louis University School of Medicine
Daniel Broadbent, MD PGY-3 St. Louis University School of Medicine
Natalie Greene, DO PGY-2 Kirksville College of Osteopathic Medicine
Mary Catherine Harrel, MD PGY-1 University of Arizona College of Medicine
Daniel Herleth, MD PGY-3 Tulane University
Sheldon Johnson, DO PGY-1 Kirksville College of Osteopathic Medicine
Kara Mayes, MD - Chief PGY-3 St. Louis University School of Medicine
Amy McClintock, MD PGY-1 St. Louis University School of Medicine
Jessica Miller, MD - Chief PGY-3 University of Missouri-Columbia School of Medicine
Rebecca Rodriguez, MD PGY-2 St. Matthewâ&#x20AC;&#x2122;s University School of Medicine
Patrick Rose, MD PGY-2 St. Louis University School of Medicine
Joseph Schuster, DO PGY-1 Kirksville College of Osteopathic Medicine
Shane Stephenson, MD PGY-2 St. Louis University School of Medicine
Dawn Talbert, DO PGY-2 Kirksville College of Osteopathic Medicine
Anjani Urban, MD PGY-2 St. Louis University School of Medicine
Jennifer Wessels, MD PGY-3 St. Louis University School of Medicine
Family Medicine Staff Roster 2011-2012 PGY = Post Graduate year. For additional copies, please call Graduate Medical Education.
UMKC FMR Hosted ALSO® Provider Course UMKC Family Medicine Residency Program located at Truman Medical Center-Lakewood, hosted a two-day course in Advanced Life Support in Obstetrics (ALSO) on February 3-4, 2012. During the hands-on instruction, participants Pictured above (left to right) are Suzan "Annie" Lewis, DO, Britney Else, DO, Avery Abernathy, DO, Kelly Jo Easley, MD, (all RES1) and Todd Shaffer, MD. were given a procedural education of the different emergencies that may arise in obstetrics. Lessons consisted of lectures and small group workstations, during which the participants utilized pelvic mannequins provided by the Family Health Foundation of Missouri. MAFP members may utilize the mannequins for educational presentations by contacting MAFP Staff at office@mo-afp.org or by calling (573) 635-0830.
About ALSO Advanced Life Support in Obstetrics (ALSO) helps physicians and other health care providers develop and maintain the knowledge and skills they need to effectively manage potential emergencies during the perinatal period. The program additionally serves as an aid for training residents in obstetrics as well as family medicine.
ALSO emphasizes labor and delivery room emergencies but also covers: • • • •
Prenatal risk assessment First-trimester bleeding Consultant relationships Helping parents cope with a birth crisis • Information on reducing medical malpractice risk
Contact ALSO For information on ALSO Provider Courses, about ALSO Instructor Courses, and the ALSO International, GLOBAL ALSO, and the Basic Life Support in Obstetrics (BLSO) Program as well as the CareTeam OB Program (Patient Safety), please contact the AAFP ALSO Staff at 1-800-274-2237, or visit www.aafp.org/also.
Pictured above left (left to right), includes two visiting residents along with Angela Divjak, MD and Wael Mourad, MD (both seated). Pictured above right are Kelly Jo Easley, MD (RES1) and Todd Shaffer, MD. Missouri Family Physician April - June 2012 17
MAFP ABFM mc-fp update
ABFM Maintenance of Certification Update Registration for 2012 MC-FP exams now open Registration for the April 2012 MC-FP Examinations (Certification & Recertification) is now open. Beginning in 2012, the ABFM MC-FP examination will be held in April instead of July. April 2012 MC-FP Examination Dates: April 6, 7, 9, 10, 11, 12, 13, 16, 17, 18, 19, 21 Diplomates can access the application for the April examination beginning December 8, 2011 at www.theabfm.org by logging in to their physician portfolio with their ABFM ID/Username and password and following the steps below. Diplomates who do not know their ABFM ID/Username and password should contact the ABFM Support Center.
modification since Maintenance of Certification (MC-FP) began in 2003 - "Continuous MC-FP." For those of you who certified in 2011, and everyone who certifies in all future years, there is no longer a 7-year certification; all will be in the 10-year program. This makes the successful completion of each 3-year window, called "stage" essential in maintaining this 10-year plan.
ABFM offers completion of Part IV Maintenance of Certification module in one week Attention! Now you can complete a Part IV module in your Maintenance of Certification in ONE week! For more information on this process please contact the ABFM directly or visit www.theabfm.org/moc/ part4.
Questions? Need help? Contact the ABFM Support Center at 1-877-223-7437 or email: help@theabfm.org
Now you can provide a complete allergy testing and immunotherapy service line.
To activate the online application for the exam: 1. Review personal information and update if necessary 2. Click MC-FP Examination under Track Your Progress 3. Click Request Application 4. Click Continue 5. Click Begin Application The MC-FP Examination will also be offered in November for candidates who fail the spring administration of the examination, or for those residents in good standing who are off-cycle and are expected to complete training on or about December 31, 2012.The application for the November exam is expected to open in August 2012. November 2012 MC-FP Examination Dates: November 7, 8, 9, 10 Update on Continuous MC-FP The American Board of Family Medicine recently implemented the most significant 18 Missouri Family Physician April - June 2012
Your patients no longer have to suffer from seasonal allergies and you don’t have to risk losing them by referring out to specialists. By offering this service line, physicians are able to provide a higher level of care to a large portion of their patient base, while generating a new revenue stream.
About United Allergy Labs and our service: • We hire and train a Certified Clinical Allergy Lab Specialist to test, educate and custom build immunotherapy under the supervision of the on-site physician. • Provide all supplies and materials related to the service line.
• Focus efforts on patient safety, patient compliance and patient outcomes • Allow you to treat allergy patients rather than cover their symptoms with medications.
Interested in becoming a UAL Allergy Center? Visit www.UnitedAllergyLabs.com or call 210.265.3181.
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Missouri Family Physician April - June 2012 19
MAFP asa schedule of events Thursday, June 21 1:30 - 3:30 pm
Commission Meetings
3:30 - 7:00 pm
MAFP & FHFM Board Meetings
Friday, June 22 7:00 - 8:00 am
Registration & Breakfast Buffet with Exhibitors Sponsored by Missouri Professionals Mutual
7:00 - 11:00 am
Exhibit Hall Open
7:55 am
Welcome and Introductions James Stevermer, MD, MSPH Chair, MAFP Education Commission
8:00 - 10:00 am
Disaster Preparedness and Response: The Big Picture & Disaster Preparedness and Response: Your Picture Andrew Spain
10:00 - 10:30 am
Refreshment Break with Exhibitors
10:30 - 11:30 am
Narrowing the Gap in Vaccine Coverage Among At-Risk Adults Jorge P. Parada, MD, MPH, FACP, FIDSA
11:30 am - 12:30 pm
Annual Business Meeting & Legislative Update Luncheon
12:30 - 2:00 pm
Getting to Goal With Patient-Centered Diabetes Care Kevin Peterson, MD, MPH Donna Tomky, MSN, RN, C-NP, CDE, FAADE
2:00 - 2:30 pm
Refreshment Break with Exhibitors
2:30 - 4:00 pm
Responsible Prescribing of Opioids for the Management of Chronic Pain Gary Ruoff, MD
4:00 - 5:00 pm
Practice-Changing Updates from Literature James Stevermer, MD, MSPH
6:00 - 7:30 pm
Family Fun Picnic
Saturday, June 23 7:00 - 8:00 am
Registration & Breakfast Buffet with Exhibitors Sponsored by Missouri Professionals Mutual
7:00 - 11:00 am
Exhibit Hall Open
8:00 - 9:00 am
Endoscopy in Family Medicine 1979-2012 Wm. MacMillan Rodney, MD
9:00 - 10:00 am
Bariatric Surgery Complications - Beyond the First 30 Days Christopher Kowalski, MD
10:00 - 10:30 am
Refreshment Break with Exhibitors Sponsored by Midwest Dairy Council
10:30 - 11:30 am
Patient Centered Medical Home - Where's the Value? Shelly Finney, MBA Michael O'Dell, MD, MBA
11:30 am - 12:30 pm
Bedside OB-GYN Ultrasound: The Family Medicine Office as the Point of Service Wm. MacMillan Rodney, MD
20 Missouri Family Physician April - June 2012
asa schedule of events MAFP
Saturday, June 23 (continued) 12:30 - 2:00 pm
Awards & Installation Luncheon • 2012 MAFP Family Physician of the Year • AAFP Degree of Fellow Convocation • Soaring Eagle Award Presentation • Installation of 2012 Board Members and MAFP President
2:30 - 4:00 pm
Social Mixer - Meet and Greet the Future of Family Medicine Poster Presentations and Awards Hors d'oeuvres Reception (All physician attendees are encouraged to participate)
Sunday, June 24 7:00 - 7:30 am
Breakfast
7:30 - 8:30 am 8:30 - 9:30 am 9:30 - 10:30 am
Roundtable Discussion (repeated back-to-back) Roundtable Discussion (repeated back-to-back) Roundtable Discussion (repeated back-to-back) Highlight on Diabetes Initiative Peter Koopman, MD Preceptor Issues Jeffrey Suzewits, DO, MPH Health Policy Update Robert Schneider, DO TBD Kate Lichtenberg, DO, MPH
$50 Early-Bird Discount Available Until 4/30/2012 Conference Registration Mail your registration today. Registration is also available online with MasterCard, Visa, Discover, or PayPal at www.mo-afp.org or Fax to: (573) 635-0148 or Phone MAFP (573) 635-0830 CME Application for Accreditation has been filed with the American Academy of Family Physicians for up to 14 CME credits. Determination of Credit is pending. Disclosure Policy It is the policy of MAFP to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational programs. All faculty participating in MAFP-sponsored programs are expected to disclose to the program audience any association or apparent conflicts of interst related to the content of their presentation(s). Cancellations & Refunds All requests for conference refunds must be made in writing or emailed to office@mo-afp.org and received no later than May 22, 2012. MAFP policy requires a $25 administrative fee be deducted from each refund processed. Hotel Registration The Resort at Port Arrowhead 3080 Bagnell Dam Blvd., Lake Ozark, MO 65049 Toll-free: 800-532-3575 • Phone: 573-365-2334 E-mail: reservations@theresortatportarrowhead.com The MAFP block of rooms and group rate of $91 per night (plus tax) is valid through May 22, 2012. GROUP CODE: MAFP12
Missouri Family Physician April - June 2012 21
22 Missouri Family Physician April - June 2012
2012 asa registration form MAFP
Missouri Family Physician April - June 2012 23
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