Mafp magazine apr jun 2014 final for web by Missouri Academy of Family Physicians

MISSOURI

Official Publication of the Missouri Academy of Family Physicians

Family Physician

April - June 2014 Volume 33, Issue 2

Family Medicine Congressional Conference April 7-8, 2014 Washington, DC pg. 16

Welcome New Executive Director Kathy Pabst pg. 6

PCMH and Recruiting Gen X Family Medictine Graduates pg. 10

Resident Grand Rounds

Christopher Howse, MD Margaret Day, MD pg. 12

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Contents MAFP

Mark your Executive Commission Board Chair - Kate Lichtenberg, DO, MPH (Kirkwood) President - Bill Fish, MD (Liberty) President-elect - Daniel Purdom, MD (Kansas City) Vice President - Peter Koopman, MD (Columbia) Secretary/Treasurer - Tracy Godfrey, MD (Joplin) Board of Directors District 1 Director: Dana Granberg, MD Alternate: Jennifer Moretina, MD District 2 Director: Lisa Mayes, DO Alternate: Vacant District 3 Director: F. David Schneider, MD Director: Caroline Rudnick, MD Alternate: Sarah Cole, DO District 4 Director: Vacant Alternate: Vacant District 5 Director: James Stevermer, MD, MSPH Director: Vacant Alternate: Vacant District 6 Director: Jamie Ulbrich, MD Alternate: Vacant District 7 Director: Kathleen Eubanks-Meng, DO Director: Jeff Suzewits, DO, MPH Alternate: Vacant District 8 Director: Mark Woods, MD Director: John Paulson, DO, PhD Alternate: Charlie Rasmussen, DO District 9 Director: Vacant Alternate: Vacant District 10 Director: Mark Schabbing, MD Alternate: Steven Douglas, MD Resident Directors Imani Anwisye, MD Betsy Wan, MD (Alternate)

MAFP 66th Annual Scientific Assembly (ASA) June 6-8, 2014 Lodge of Four Seasons Still time to register See pg.9 Lake Ozark, MO MAFP Board & Commission Meetings June 8, 2014 AAFP National Conference of Family Medicine Residents & Students August 7-9, 2014 Kansas City Convention Center Kansas City, MO

MAFP Missouri Reception (in conjunction with NCFMRS) August 8, 2014 Midland Theatre (Lower Lobby) Kansas City, MO MAFP 22nd Annual (AFC) & SAM Working Group November 7-9, 2014 Big Cedar Lodge Ridgedale, MO MAFP Board & Commission Meetings November 8, 2014

Earn up to 13.50

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Join us for the 66th Annual Scientific Assembly to be held at The Lodge of Four Seasons Lake Ozark, MO

June 6 - 7, 2014 Register online now!

www.4seasonsresort.com New to summer conference: • Refer a colleague for chance to win an iPad mini • Reduced registration fee for non-physician attendees • "New Physician" discounted registration fee (within 7 years of residency completion) • Office manager or coder may attend the ICD-10 lecture at no cost

Visit www.mo-afp.org for Schedule of Events, Speakers, Accommodations

Inside this issue

Student Directors Amanda Williams Sarah Williams (Alternate) AAFP Delegates Larry Rues, MD Darryl Nelson, MD Bruce Preston, MD (Alternate) Keith Ratcliff, MD (Alternate) MAFP Staff Executive Director - Kathy Pabst Education & Finance Director - Nancy Griffin Member Services/ Managing Editor - Laurie Bernskoetter Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p (573) 635-0830 www.mo-afp.org

Calendar

f (573) 635-0148 office@mo-afp.org

Board Chair Update

Member Services Update

Welcome Kathy Pabst

Help Desk Answers

Annual Scientific Assembly

2014 Match

Kate Lichtenberg, DO, MPH, FAAFP Kathleen Eubanks-Meng, DO

17 Advocacy Day 17 Physician of the Year Nominees 19 Tar Wars Program Continues to Make a Difference in Missouri Schools

New Executive Director Resident Case Studies

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Missouri Health Professional Placement Services

10 PCMH and Recruiting Gen X Family 8 Medicine Graduates Todd D. Shaffer, MD, MBA, FAAFP 11 12 Resident Grand Rounds 15 Christopher Howse, MD Margaret Day, MD

16 Members in the News

Family Physicians Inquiries Network OAFP CME Webinars Physicians Professional Indemnity Association (PPIA)

18 U.S. Army Healthcare 20 Missouri Professionals Mutual (MPM) Missouri Family Physician April - June 2014

MAFP Board Chair Update

Kate Lichtenberg, DO, MPH, FAAFP 2013-2014 MAFP Board Chair

he MAFP Board of Directors would like to thank Dr. Arthur Freeland for his tireless work on behalf of the Academy. Dr. Freeland is a past board president and advocacy commission co-chair. Dr. Jamie Ulbrich will be stepping up to co-chair the Advocacy Commission with Dr. Keith Ratcliff. We look forward to Dr. Ulbrich's leadership. Dr. Tracy Godfrey has stepped down as Treasurer for the Academy. She also served on the board prior to taking over as Treasurer. We thank her for her service as well. Our new Treasurer will be announced soon.â&#x2013;

Arthur Freeland, MD Kirksville, MO

Jamie Ulbrich, MD Marshall, MO

Tracy Godfrey, MD Joplin, MO

Congratulations Missouri Academy! AAFP recently announced the 2013 Chapter Membership Awards which were presented at the ALF/NCSC luncheon on Friday, May 2, 2014 in Kansas City. Missouri staff and delegates were recognized for its efforts in the Large Chapter category: Highest percent retention of active members as of December 31, 2013 1 Place - Iowa 2nd Place - Missouri, North Carolina st

Highest percent retention of new physicians as of December 31, 2013 1 Place - Missouri 2nd Place - Iowa, Kansas st

Missouri Family Physician April - June 2014

Chapters at 100% for Resident Membership for 2013-2014 as of March 31, 2014

Highest total contributions donated by members to FamMedPAC as of December 31, 2013

Missouri is among 39 other state chapters who received this award.

Large - California

Highest percent increase in active membership as of December 31, 2013 1st Place - Georgia 2nd Place - Michigan Highest percent increase in student membership as of December 31, 2013 1st Place - Uniformed Services 2nd Place - Indiana

Highest percentage of membership making a contribution to FamMedPAC as of December 31, 2013 Connecticut As you can see, your MAFP staff has been busy working for our members, medical students, residents, and new physicians. We want to continue this excellence as we look for future growth of the Missouri Academy. We could not be successful without the support of you, our members. THANK YOU!

Member Services Update MAFP

Kathleen Eubanks-Meng, DO 2013-2014 MAFP Member Services Commission Co-Chair

never really understood what the phrase “membership has its privileges” truly meant until I became a more active member of the Missouri Academy of Family Physicians (MAFP). I admit, after graduating from residency, receiving my dues bill was a scary experience because I did not truly understand the value of what my membership would include or the journey it would take me on. Becoming an active member has reunited me with colleagues from college and medical school. It has given me the opportunity to talk with local and state legislators about issues I face in my daily interactions with patients and has allowed me the opportunity to not only have a voice, but to truly be heard. I feel a connection to physicians in every corner of my state and have had the privilege of working with several of our state physician leaders. The energy I have received from becoming involved is infectious, encouraging, and educational. There are many opportunities to be involved in the MAFP. You do not have to have a seat on the board of directors, however, there are some alternate director positions available that are an excellent opportunity to be involved. In February, go to Jefferson City and meet with your local legislators about current legislation that affects your day-to-day patient interactions. We often hear a consistent message that physicians, specifically family physicians, are never heard from unless they want something. This day gives you the opportunity to take action and be sure they hear from you, their constituent. They are representing you, even if they never hear from you. At the national level, MAFP has representation in coordination with the American Academy of Family

Physicians at the Family Medicine Congressional Conference, which occurs in April or May. This is another opportunity to impact legislative change and give your representatives and senators “the real story.” You have a voice in Jefferson City and Washington DC, and the MAFP would love your involvement and representation. I have had the pleasure of being involved in the National Conference of Special Constituencies (NCSC)/Annual Leadership Forum (ALF), which is held annually in Kansas City, MO. NCSC legislation is presented at the AAFP Congress of Delegates (COD) regarding issues affecting New Physicians, Women, Minorities, International Medical Graduates and the GLBT community. The COD also provides an opportunity to meet with today’s family medicine leaders from across the United States and participate in leadership enrichment, development, and growth. It was here I learned the importance of social media in my practice through interaction with other physicians and to be able to stay current on multiple topics in medicine. The MAFP always has a full delegation. If you want to be involved, feel free to call. The MAFP has not increased its current dues since 2009 and continues to offer you two excellent CME conferences per year. One is offered in June at the Annual Scientific Assembly (ASA). This year it is occurring June 6-7, 2014 at the Lodge of the Four Seasons. At the ASA, students and residents have

the opportunity to participate in poster presentations at the scientific assembly. MAFP is still accepting posters from students and residents for the upcoming ASA. There is a one-day registration if you can’t be away from the office for long. The ASA is free for students and residents. The fall educational conference is at Big Cedar Lodge and will be held November 7-8, 2014. My family has enjoyed this getaway since my youngest was a baby. It is our annual escape from the busyness of our lives and time I can rejuvenate with the energy of fellow physicians, gather up-to-date information I can use in my daily practice, and spend time with my family. MAFP was recognized at the Annual Leadership Forum in May for several membership awards as a large chapter. Your patients need you to be their voice and the MAFP gives you this opportunity. Based on my experience with MAFP, membership certainly has many priviledges.■

Missouri Family Physician April - June 2014

MAFP New Executive Director

Welcome Kathy Pabst MAFP Executive Director Q: Tell us a little bit about yourself: where you grew up, what is your background? KP: I grew up in Jefferson City and was the eighth of nine children. A strong work ethic has always been a part of my character and it began at a young age. I delivered newspapers with my sisters and worked in a long-term care facility through high school. I attended college for a short time after high school and then met my husband whom I have been married to for almost 30 years. We were blessed with one child, Jeffrey who is now 27 and has a family of his own. I began working for an association management firm where I managed three non-profit associations. I was then recruited to be the office manager for the Missouri office of the American Petroleum Institute (API). While employed with API, I was responsible for managing the budget and tracking legislation impacting the petroleum industry. Determined to finish my degree, I enrolled in classes at William Woods University and graduated with a Bachelor of Science degree in Business Management. Knowing in order to advance in my career, I continued my education and earned a Master of Science degree in Business Administration. Earning these degrees opened doors in my career. I began working as the Marketing and Programs Manager for the Missouri League for Nursing (MLN), an organization that provided continuing 6

Missouri Family Physician April - June 2014

education opportunities for nursing home administrators and health care professionals. In addition, I was responsible for publishing the association newsletter, establishing a statewide mentoring program for nursing students, developing a â&#x20AC;&#x153;Master Teacherâ&#x20AC;? program for nurse educators, and collaborating with various healthcare organizations. As a result of the successful programs at the MLN, I was hired as the Director of Continuing Education at Lincoln University. I was responsible for developing and enhancing working relationships between the university and local community through outreach programs and the media. In this position, I expanded dual enrollment offerings, increased rental revenue of university facilities, spearheaded the grant writing and implementation of the Central Missouri Innovation Campus, and established a small conference center on campus. Other responsibilities included oversight of the Fort Leonard Wood Campus that offers an Associate Degree in Nursing, administration of the U.S. Army Prime Power School, and served as the liaison to Learning in Retirement. Which brings me to now . . . I am proud to be the new executive director of the Missouri Academy of Family Physicians. I am a strong leader who will represent Missouri family physicians through education and advocacy, while embracing the challenges and constant changes in healthcare. I hope to build on the current

foundation of the Academy and with the support of the members and staff, work collaboratively to advance healthcare in Missouri. Lastly, my career is very important to me; however, my family is most important. My husband is in information technology and my son, Jeff, who is married to Kara, became a father in August, 2013 . . . which means I am now a grandmother . . . the best title anyone could have. Q: What experiences do you bring to the Missouri Academy of Family Physicians? KP: Each position I have held throughout my career has built upon the previous. I have over 15 years experience working with non-profit organizations. When working for an association management company, I learned to wear many hats and meet the needs of a statewide trade association, a national trade association and a statewide professional organization. These diverse groups allowed me to develop processes for similar functions, yet recognize the unique benefits and characteristics of each group. My experience in association management encompasses both administrative and management responsibilities. In my position at Lincoln University, I supervised 2 staff and over 40 adjunct faculty. I worked with students who were ages 16 to over 80 years old. This was quite challenging at times, but in the end, it was all about furthering their > education. I served on committees

New Executive Director MAFP > on Assessment and Teaching and Learning during the recent reaccreditation by the Higher Learning Commission. In addition, I collaborated with internal and external stakeholders to provide outreach educational opportunities, workforce development, and further enhance the role of the university in the community. Combining this experience together with my education and the support of the MAFP staff and members, we can work together to enhance the current programs and services of the organization and develop new opportunities to advance the MAFP.

KP: The first year is going to be challenging as I learn about the profession, healthcare, and the Academy. Obviously, I want to get to know Nancy and Laurie in the MAFP office so we will be a team that provides member-centered services. I will become familiar with the organization bylaws, structure, legislative issues, office processes and event schedule. I will personally meet each board member and identify issues and opportunities that the Academy may consider for future action. I want to identify opportunities to collaborate with other organizations on programs, issues or events that impact family medicine and the Academy.

Q: What are your goals for the Academy over your first year?

Q: Where do you envision the Academy 5 years from now with all the changes to

medicine? KP: It is always difficult to look ahead with the rapid changes in medicine and technology. After learning about the Academy and its priorities, I would like to see membership increase as a result of increased collaboration with individuals and other healthcare groups. When I look back at where family medicine and technology was 5, 10, or even 20 years ago, it is staggering to imagine the future. The younger generations use social media as a means to communicate and stay abreast of current events . . . we need to be a part of this movement. As I become more familiar with the Academy, its members and family medicine, I want to work with each of you to direct the Academy to ensure it continues to be successful and important to family physicians. Q: What else would you like our members to know about you?

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KP: All work and no play is not healthy, no pun intended. I enjoy the typical past-times of travel, reading (John Grisham and Patricia Cornwell are my favorite authors), and family . . . especially Olivia, my granddaughter. However, I have some hobbies such as creating stained glass pieces that I donate to various organizations for fundraisers. This is my creative outlet and therapy. I also enjoy the history and culture of wine, as well as wine tasting . . . especially Missouri wine which requires multiple road trips a year (with a designated driver, of course). Life is too short to not have fun, whether at work or at play. I believe that balance is important to live a healthy and happy life.â&#x2013;

MHPPS is non-profit and located within the MO Primary Care Association Missouri Family Physician April - June 2014

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!

Is cognitive behavior therapy an effective treatment for irritable bowel syndrome? Evidence-Based Answer

Cognitive behavior therapy (CBT) may be effective for reducing irritable bowel syndrome (IBS) symptom severity immediately following treatment and for up to 3 months (SOR: C, conflicting meta-analyses and a small RCT). There is no evidence of efficacy persisting beyond 6 months (SOR: A, meta-analysis). A 2009 systematic review of 7 RCTs (527 patients aged ≥17 years) examined the efficacy of CBT compared with usual management for the reduction in IBS symptoms immediately after treatment.1 Of the patients assigned to CBT, 42% had persistent IBS symptoms compared with 61% of patients in the control group (risk ratio [RR] 0.60; 95% CI, 0.42–0.87). None of the studies examined long-term follow-up. A 2009 Cochrane systematic review that included 17 RCTs (817 patients aged ≥16 years) also evaluated the effectiveness of CBT for IBS.2 Outcomes were symptom score improvement and abdominal pain. Studies comparing CBT with usual care found no difference in symptom score improvement (scoring not defined) at 2-month follow-up (4 trials, N=133; standardized mean difference [SMD] 0.75; 95% CI, –0.20 to 1.7), although there was a small difference at 3 months (5 trials; N=378; SMD 0.58; 95% CI, 0.36–0.79). Studies comparing CBT with placebo showed no differences on symptom scores at 2-month (5 trials, N=230; SMD 0.68; 95% CI, –0.01 to 1.4) or 3-month follow-up (5 trials, N=230; SMD –0.17; 95% CI, –0.45 to 0.11). There was no difference in abdominal pain at 2 or 3 months with either CBT or usual care and no difference in symptom scores at 6-month follow-up. A recent RCT compared 8 weeks of mindfulness training, a form of CBT, with a support group control on IBS severity, abdominal pain severity, and abdominal pain frequency in 75 women.3 Outcomes were assessed at pretreatment, immediately after treatment, and at 3-months follow-up using repeated-measures analysis of variance (ANOVA) to compare group differences over time and paired t-tests to assess differences in individual symptoms. Women in the treatment group reported greater reduction in IBS severity than those in the control group immediately after treatment (26% vs 6% reduction; P=.006) and at 3-months followup (38% vs 12% reduction; P=.001). On a 100-point scale, patients in the treatment group had lower abdominal pain severity scores 8

Missouri Family Physician April - June 2014

February 2014 EBP

than patients in the control group immediately after treatment (35 vs 50; P=.01) and at 3-months follow-up (31 vs 46; P=.01) as well as fewer episodes of abdominal pain in the previous 10 days at 3-months follow-up (3.1 vs 4.6; P=.007).3 Kelly M. Everard, PhD Kimberly Zoberi, MD St. Louis University St. Louis, MO 1. Ford AC, et al. Gut. 2009; 58(3):367–378. [STEP 1] 2. Zijdenbos IL, et al. Cochrane Database Syst Rev. 2009; (1):CD006442. [STEP 1] 3. Gaylord SA, et al. Am J Gastroenterol. 2011; 106(9):1678– 1688. [STEP 2]

From the authors who bring you HelpDesk Answers comes a relevant, concise, and clinically useful journal to assist you in delivering the best care to your patients –all without the bias of industry support. Evidence-Based Practice is published monthly by the Family Physicians Inquiries Network. 12 issues and 48 PRA Category 1 CME CreditsTM $119 Missouri Family Physician Reader or $59 FPIN Member To subscribe, or view a sample issue, visit www.ebponline.net or call 573-256-2066.

Earn CME /2014 Match MAFP

Earn up to 13.50

Still time to register!

CME credits

Join us for the 66th Annual Scientific Assembly to be held at The Lodge of Four Seasons Lake Ozark, MO

June 6 - 7, 2014 Register online now! Visit www.mo-afp.org for Schedule of Events, Speakers, Accommodations

Family Medicine Match Rate Increases for Fifth Consecutive Year by Sheri Porter, AAFP News Now (posted March 21, 2014)

Following an anxious week of waiting, graduating medical students today learned the results of the 2014 National Resident Matching Program (NRMP), commonly referred to as the Match. Those results spotlight a positive trend for family medicine: For the fifth straight year, the number of medical students choosing family medicine ticked higher than the previous year. Specifically, 3,000 students, including both US medical school graduates and international medical graduates, chose family medicine; that figure represents a 2 percent increase (62 more positions filled) compared with the 2,938 family medicine spots filled in 2013. Moreover, of this year's total, 1,416 US seniors matched to family medicine; that's 42 more than in 2013, or a 3 percent increase. Finally, a total of 70 more family

medicine residency positions were offered in 2014 compared with 2013 (3,132 versus 3,062), yet the higher number of students matching into the specialty maintained the same fill rate of 96 percent.

Pictured above is Kanika Turner on Match Day 2014 at Saint Louis University (SLU). Ms. Turner is one of the new residents in the SLU St. Mary's/Family Care Health Center program.

Pictured above are University of Missouri - Columbia medical students who have ‘earned their stripes’ and will be continuing with the Family Medicine Residency at Mizzou. (Left to Right) Chase Ellingsworth, Andrea Schuster, Erin Pearson, and Veronica Conaway

Do you know a medical student interested in family medicine? Talk to them about becoming a member. Student Membership is FREE! Visit http://www.aafp.org/about/ membership/join/student.html Missouri Family Physician April - June 2014

MAFP PCMH and Recruiting Gen X FMGs

PCMH and Recruiting Gen X Family Medicine Graduates by Todd D. Shaffer, MD, MBA, FAAFP Is Missouri ready for the new generation of highly trained family doctors? We talk about how important it is for our state to be able to train the future primary care physicians. We struggle in a state that has few resources that encourage medical students to remain in our state for their residency training and even fewer resources after practice. The Graham Center reports that 56% of residency program graduates will enter practice within 100 miles of where they completed their training. Yet, ACGME data shows that Missouri ranks 47 out of 50 in retaining its medical school graduates. Despite continuous efforts at levels of the MAFP and primary care organizations, including PRIMO, Missouri lags far behind our surrounding states in their progressive methods for loan repayment and encouraging students to enter family medicine. Missouri currently produces approximately 59 family physicians per year in our six ACGME accredited programs. We have yet to see the pending work-force studies. Just how short are we on producing enough family medicine physicians for our population? It is hard to find those numbers for Missouri primary care practices. Nationally, more than 6,800 sites and over 30,000 physicians are certified by NCQA. Wait — Are we ready? We have been hearing about this since the Future of Family Medicine (FFM) 1.0 Project asked us to transform back in the early 2000’s. Yet, how many of our practices across the state have heeded the directive by our “family of families” (i.e., AAFP, ABFM, STFM, AFMRD, etc.) to transform our practices into a full-fledged PCMH? I did a recent survey of our residency training programs and four of the programs are training new graduates of residencies in full 10 Missouri Family Physician April - June 2014

fledged Level III NCQA certified residency programs. Cox, Saint Louis University, Research and UMKC have all made the transition to Level III PCMHs. Mizzou is working to complete their application and Mercy is a Level I PCMH. It has been a challenge for each of the programs to make the changes, but it is a reflection of where our specialty is going. We must be able to thrive in the future healthcare system — payment models are changing and delivery of care will be population based. All of the family medicine residents in Missouri graduating from an ACGME program this year will have been trained in PCMH models of care. What will they be looking for when taking jobs fresh out of residency training? Will they look for practices that are already transformed? Maybe they could be the transform agents themselves. With constant quality improvement cycles that are now required in residency training, it takes a lot of effort and buy in to truly move forward to the PCMH model. It is not how much we know medically now, but that we know how to provide care for the populations we serve in a more efficient manner. Residents have expectations for how and where they will practice family medicine in a relationship-centered specialty. That relationship is what brings people into family medicine and is the center of who we are and what we do. PCMH practices build and support those relationships as individuals and as communities for improved quality of care. Having a primary care physician rather than a specialist physician for their regular source of care has lower subsequent fiveyear mortality rates when case adjusted for other determinants of health. I have been privy to the Future of Family Medicine (FFM) 2.0 Project findings

that will be released later this fall. Some is still confidential, but there are a lot of great things about the project that are coming. There is a lot of great support for family medicine being the primary care options for most patients in the U.S. Patients, payors, and other specialists see the value and the importance of what we do in our delivery of complexity of care. Because of this, the future of primary care in the PCMH is like the general practice of the past with a steroid shot of an EHR and population management with the family physician at the helm. Whether you agree with the affordable health care act or not, it has positioned the PCMH and primary care at the forefront of healthcare. PCMHs hinge on relationships in team-based care with accessibility outside of the clinic holding a wide scope of practice, while being measured with metrics showing high quality and affordable care needed for the triple aim: Better health; Better care; and Lower cost. The PCMH process has shown evidence that it can attain the triple aim and is already happening in these advanced practices. I have given the main concepts here and you will also have happier and more engaged patients taking charge of their own health as well as further boosting your measured outcomes. Then there is always money . . . Well, you don’t get something for nothing. This is the right thing to do. Two of the residency programs I talked with received financial support from insurance companies. One had their money sent elsewhere in the process and was only able to meet the level I NCQA criteria at this point. Another received a grant from Medicaid to create a PCMH for MO Medicaid patients. Payments for these processes have meant minimal increases from payors. We need to have a different

PCMH and Recruiting Gen X FMGs MAFP payment model to really pay us for our outcomes and not for providing more to each patient in the fee for service environment. What are your barriers? Recent issues in a poll suggested these are time, staffing, not understanding the benefit, personal buyin, and cost. These all need to be dealt with to proceed forward. Time needs to be set aside and change agents can help with ideas of how they found the time to get started. Staffing needs change to have everyone work at the level of their license. We can have team-based care that optimizes all caregivers in our clinic, challenges them for a more rewarding career, and allows us to do physician work. The FFM 1.0 Project addressed most of these things but never really fixed the payment part. There are some new monies coming for outcomes and data reporting that are made easier and with better outcomes in PCMH practices. Family physicians have the highest upstream of medical expenses per salary than any other specialty as reported by Merritt Hawkins. In fact, they generate about nine times their salary in upstream revenue. Hospitals and care plans see family physicians as cost containers but also as feeders for their entire systems of the medical establishment we have now. No wonder that upwards of 62% of practicing physicians are employed and over 90% of new grads are looking for employment in their future practice as outlined by a member of a recent AAFP member survey. Family physician leaders need to hold their heads high during negotiations with payers and should be well rewarded for their cost savings and patient outcomes. Insurance companies have large scale demonstration projects showing the value of primary care. We know it exists, but just as we are the Show ME State, everyone has to show us before we believe. The future FFM 2.0 Project will try to address this issue with a Direct Payment Model that will pay us for the work and outcomes we achieve directly from the consumer. Other blended models may fall by the wayside when we really get paid directly for what we do by the consumer. You will be hearing much more about this model from the AAFP later this summer.

This is a checklist I created for you when hiring new grads: • Do we have a certified PCMH practice? • Do we have an EHR? • Do we have patient registry? (28% of family physicians report using a registry to facilitate population health management). • Do we work in teams? • Does our practice have advanced access of “After Hours Care” and electronic asynchronous communication directly with their family physician? (Did you know that a recent PEW research article stated that 60% of US Health Consumers are willing to switch providers to gain access to their electronic medical records). • Do we have practice styles and lifestyles ready for Gen Xrs? • Do we have alternative payment styles available for Direct Payment Options? Recruiting a family physician is no longer about whether your community has a golf course or a symphony — it is about whether the practice they are joining is PCMH recognized. These are the new wave of graduates looking to practice in the future PCMH's manner. Although, this is still family medicine, your practice needs to be in the PCMH style ready for the bright future of family medicine. We need family physicians in a PCMH practice guided by the triple aim and the Four Pillars of Primary Care: • • • •

Pipeline Process of Medical Education Practice Transformation Payment Reform

When we have these as our guiding light and you have checked everything off your list, we will succeed bringing these together, attracting and retaining the best and the brightest into family medicine into Missouri for the betterment of all.

A Heart Healthy Diet:

Should We Be Updating Our Recommendations? Missouri family physicians and other healthcare professionals are invited to view two webinars offered for Continuing Medical Education credit through February 2015. Each webinar is approved for 1 Prescribed credit by the American Academy of Family Physicians. There is no cost to participate.

Red Meat, Lean Beef, and Heart Disease: An Overview of the Evidence Michael R. Roussell, PhD

This one-hour web presentation offers new information to consider when advising patients who are adopting a heart-healthy diet and lifestyle as a preventative or risk reduction strategy for cardiovascular disease.

THE BOLD DIET

Clinical Findings and Practical Application Michael R. Roussell, PhD

This one-hour web presentation describes the Beef in an Optimal Lean Diet study (BOLD), previously published in the American Journal of Clinical Nutrition, and the observed impacts on patient health and cardiovascular disease risk factors.

Web-based presentations for Missouri family physicians and other healthcare professionals offered by our affiliate chapter, the Oklahoma Academy of Family Physicians.

www.heart-healthynutrition.com

This educational opportunity is offered by the Oklahoma Academy of Family Physicians, a state chapter of the American Academy of Family Physicians (AAFP) which represents over 105,000 physicians, residents and medical students in the United States.

Educational grant support for the program provided by the Oklahoma Beef Council and supported by the Missouri Beef Council.

Missouri Family Physician April - June 2014

MAFP Resident Grand Rounds

A Case of Brucellosis in Central Missouri Presenting with Symptoms of Recurrent Fever and Malaise in a Cirrhotic Patient with Recent Travel to Mexico Christopher Howse, MD Margaret Day, MD Department of Family & Community Medicine University of Missouri - Columbia, Missouri Abstract Human brucellosis is rare in the United States, particularly in the Midwest, yet remains one of the world’s most common zoonotic infections. A thorough history, including risk factors for contracting brucellosis, is important in making the diagnosis. Appropriate identification and treatment of brucellosis can decrease morbidity and mortality, as the disease can cause chronic infection and exacerbate preexisting conditions. We report a case of a 51-year-old Hispanic male with alcoholic liver cirrhosis presenting with fever and malaise in Missouri. Patient Summary A 51-year-old Hispanic male presented to the emergency department at University of Missouri Healthcare with complaints of worsening fatigue and malaise over the prior two weeks. He reported fevers reaching 102-103° F (38.8-39.4 C). Other symptoms included worsening dyspnea, decreased appetite, nausea, loose stools, and weight loss. Past medical history was significant for alcoholic cirrhosis, chronic thrombocytopenia, and prior hepatitis A infection. He reported a history of multiple trips to Mexico to visit family, most recently four months prior to admission. Upon initial evaluation, patient was found to be alert, oriented, and in no acute distress. He was afebrile with stable vital signs. Physical exam was significant for a soft, non-tender, and non-distended abdomen with liver edge palpable 3 cm below the costal margin and no obvious 12 Missouri Family Physician April - June 2014

ascites. Notably, his right lower extremity exhibited diffuse, tender palpable purpura. His bilateral lower extremities showed brawny skin changes, consistent with chronic venous insufficiency. No focal neurologic deficits were noted. He had mild bilateral scleral icterus. Admission laboratory results (Table 1) were notable for a platelet count of 33,000/ mcL (prior baseline of 40,000-60,000/ mcL). He was mildly hyponatremic with serum sodium level of 127 mmol/L. Blood cultures were obtained. Urinalysis was notable for positive nitrites and blood along with trace bacteria. Findings on chest x-ray were consistent with atypical pneumonia. Abdominal CT results showed evidence of liver cirrhosis with portal hypertension without ascites. Based on this initial diagnostic work-up, the patient was started on a 5-day course of oral azithromycin (500 mg for one day, 250 mg for subsequent four days) for atypical pneumonia coverage and ceftriaxone 2 g IV q24 hours to cover for both pathogens of community acquired pneumonia and pyelonephritis, as well as empiric coverage for possible spontaneous bacterial peritonitis (SBP). Due to continued concern for SBP, an abdominal ultrasound was performed to look for ascitic fluid not found on physical exam or CT imaging. Although no large pockets of fluid could be found, a diagnostic paracentesis was able to retrieve 100mL of champagne-colored fluid. There was no evidence of SBP based on fluid analysis, though the paracentesis was

Christopher Howse, MD

Margaret Day, MD

obtained following initiation of antibiotics. Course of Illness Despite coverage with azithromycin and ceftriaxone, he continued to have intermittent fever. Two sets of peripheral blood cultures from admission and subsequent days grew Gram negative rods in 1 out of 2 bottles. Ceftriaxone was discontinued in favor of ciprofloxacin 500mg BID to provide improved Gram negative coverage. A transthoracic echocardiogram was obtained, showing no evidence of endocarditis. Five days into patient’s hospital course, identification of initial blood cultures was reported as positive for Brucella species. An isolate was sent to the Missouri State Public Health Lab for confirmation then to Center for Disease Control Laboratory for speciation, and was eventually identified as Brucella abortus. Additional information regarding our patient’s travels to Mexico revealed he worked closely with livestock, specifically cattle. He was involved in the delivery of multiple calves, some of which were stillbirths. The patient also consumed unpasteurized milk products. Treatment was initiated with combination of doxycycline 100mg PO BID x 6 weeks, rifampin 600mg PO daily x 6 weeks, and gentamicin 5mg/kg (520mg) IV q24hr for 7-10days. He completed four days of this regimen as an inpatient with resolution of fever and improvement of other constitutional symptoms prior to discharge. He was scheduled to receive

Resident Grand Rounds MAFP WBC 7.6 10-3/mcL Differential (automated):  89.1% Granulocytes  7.0% Lymphocytes  3.8% Monocytes RBC 4.05 10-6/mcL HBG 13.6 g/dL HCT 39.0% MCV 96.4 fL MCH 33.5 pg MCHC 34.7 g/dL RDW 14.7% PLT 33 10-3/mcL Urinalysis:  Sp. gravity 1.025  pH 6.5  Glucose 100 mg/dL  Trace ketones  Large bilirubin  Large blood  Negative leukocytes  Positive nitrites  > 300 mg/dL protein  15-20 RBC/hpf  Trace bacteria Urine culture: negative

(4.5-11.0)

Table 1. Admission Laboratory Values Sodium 127 mmol/L Potassium Hemolyzed (subsequent value of 4.2 mmol/L)

(4.60-6.20) (13.5-18.0) (40.0-54.0) (80.0-96.0) (27.0-31.0) (32.0-36.0) (11.5-14.5) (150-400)

three subsequent gentamicin doses intramuscularly at his local healthcare facility as an outpatient. Following discharge, our patient was readmitted several times. He initially returned one week post-discharge with symptoms of nausea, vomiting, anorexia, and hyperbilirubinemia. There was concern that symptoms were due to his antibiotic regimen. He was therefore changed to a 4-week course of Bactrim DS (sulfamethoxazole 400mg/trimethoprim 80mg) BID and ciprofloxacin 500mg PO BID to complete his 6-week total antibiotic course. Subsequent readmissions were related to issues with patient’s cirrhosis, and, given the acceleration of his disease

Chloride CO2 Glucose BUN Cr Ca Albumin Total bilirubin Alkaline phosphatase AST-SGOT

102 mmol/L 20 mmol/L 102 mg/dL 22 mg/dL 1.12 mg/dL 7.8 mg/dL 2.1 g/dL 1.6 mg/dL Hemolyzed (subsequent value of 169) Hemolyzed (subsequent value of 154) ALT-SGOT 113 units/L Lipase 87 unit/L Comprehensive urine drug screen: negative Acetaminophen and ethanol blood level samples were hemolyzed and not repeated due to low clinical suspicion of abuse

Salicylates level

<3.0 mcg/mL

course, it is likely brucellosis played a role in exacerbation of his hepatic disease. Unfortunately, he passed away due to complications of cirrhosis approximately four months following his initial admission. Discussion Brucella spp. is an aerobic Gram negative coccobacilli causing brucellosis, a zoonosis typically associated with exposure to infected livestock or contaminated animal products. The bacteria enter the body via ingestion, inhalation, conjunctiva, or open skin wounds. They are able to avoid host defenses, penetrate host cells, and multiply within the phagocytic cells of the reticuloendothelial system.1 Endotoxins

Table 2. Endemic areas for brucellosis Mediterranean Basin (Portugal, Spain, Southern France, Italy, Greece, Turkey, North Africa) Mexico Central and South America Eastern Europe Asia Africa The Caribbean Middle East Adapted from http://www.cdc.gov/brucellosis/exposure/areas.html

(136-145) (3.5-5.1)

(98-107) (22-29) (74-109) (6-20) (0.67-1.17) (8.6-10.2) (3.5-5.2) (0.1-1.2) (40-129)

are then released from within phagocytic cells, producing the constitutional symptoms and early signs of disease associated with brucellosis. This intracellular process may explain, in part, why not all patients present with clinical bacteremia (< 70%).2,3 The incubation period is variable, ranging from days to months, but typically is around 2-4 weeks after inoculation.4

(0-40)

The major risk factors for contracting Brucella spp. are travel to endemic areas (Table 2), contact with infected meats or the placenta of infected animals, and ingestion of unpasteurized milk products.5 Four Brucella spp. are known to cause human disease. Brucella abortus is found in cattle, as well as moose, caribou, bison, and elk, and causes issues with bovine fetal development and viability, leading to spontaneous abortions. Brucella melitenesis, which is thought to cause the most severe human disease, is associated with exposure to goats and sheep or unpasteurized milk, cheeses.3,4 Brucella suis is associated with exposure to infected swine and Brucella canis is associated with exposure to infected canines.3

(10-50) (13-60)

Thanks to increased efforts to eradicate the disease within the livestock population over the past half-century, the number of reported human infections in the United States has decreased from 6,000 in 1945 to 115 in 2010, with the majority of these cases (57%) occurring in California, Arizona, Florida, and Texas (Figure 1).6 This improved domestic continued on page 14-15 Missouri Family Physician April - June 2014

MAFP Resident Grand Rounds

Brucellosis continued from page 13 Table 3. Inquiring about risk factors in patients whose symptoms are concerning for brucellosis Do you work in a slaughterhouse or meat-packing environment? Have you recently traveled out of the country? If so, where? While traveling, did you consume any undercooked meat or unpasteurized dairy products? Do you hunt? If so, have you come into contact with moose, elk, caribou, bison or wild hogs (feral swine)? Have you assisted animals giving birth? Do you work in a laboratory? If so, does the lab handle Brucella specimens? Adapted from http://www.cdc.gov/brucellosis

control of the disease is cautioned by reports that estimate < 10% of brucellosis infections in the United States are recognized and reported.7 Brucellosis is a diagnosis to consider while caring for febrile patients with risk factors (Table 3) for brucellosis. Other symptoms of brucellosis may include night sweats, fatigue, anorexia, weight loss, headache, hepatosplenomegaly, thrombocytopenia, and joint pain, with fever and osteoarticular involvement reported most commonly.1 Splenic, liver, and pulmonary abscesses may occur along with more rare manifestations including deep vein thrombosis, meningitis, and nephritis.8 Although it may be rare for brucellosis to cause fatal disease (approximately 5% of untreated patients; most commonly secondary to endocarditis from B. melitenesis), this should not diminish the importance of disease recognition and treatment. Some reports estimate that less than ten percent of brucellosis infections in the United States are recognized and reported. Brucellosis can be difficult to diagnose not only because of the disease’s nonspecific symptomology, but, as mentioned previously, less than seventy percent of those infected have evidence of bacteremia on blood cultures. Other diagnostic testing, including enzymelinked immunoabsorbant assay (ELISA), polymerase chain reaction (PCR), serum agglutination test, and Western blot, can be utilized if clinical presentation warrants further testing.1,8 Untreated patients can go on to develop severe, chronic disease affecting nearly any organ system.1 This diffuse, multi-system disease burden can 14 Missouri Family Physician April - June 2014

often trigger an exacerbation of existing underlying illness. In a series of case reports published by Jacob et al, multiple patients are described whom experience worsening of chronic hematologic, musculoskeletal, and hepatic disease (specifically, cirrhosis) following brucellosis infection.9 The WHO recommends oral treatment for brucellosis with doxycycline 200mg plus rifampicin 600-900mg daily for a minimum of 6 weeks. Concerns regarding treatment failure and relapse, along with fear of emerging rifampicin resistance in areas of endemic tuberculosis, have led to the tripledrug regimen consisting of doxycyclinerifampicin-gentamycin (gentamycin 5 mg/ kg for 7-10 day course). Multiple studies have demonstrated the efficacy of this regimen and actual reports of resistance

to treatment are very rare, with patient compliance being the most important factor in treatment failure.1,10 Conclusion Greater than 500,000 new cases of brucellosis are estimated to occur annually across the globe and the disease continues to cause serious illness within the United States.1 The clinical diagnosis of brucellosis remains a significant challenge and misdiagnosis and confusion with other diseases has led to brucellosis being labelled as a ‘major mimicker’ and a ‘disease of mistakes’.11 Untreated brucellosis infections can lead to severe, chronic disease as well as exacerbation of preexisting conditions, as was likely observed in our patient. The difficulty of proper diagnosis can be attributed to several aspects of

Number of reported brucellosis cases United States and US territories, 2010

Adapted from http://www.cdc.gov/brucellosis/resources/surveillance.html

Resident Grand Rounds MAFP

Brucellosis continued from page 14 infection, including the prolonged and variable incubation period, its frequent presentation as a non-specific febrile illness, and the involvement of multiple organs and tissues, with or without signs of focal disease. Family physicians will often encounter patients early on in the disease process and must assume an active and responsible role in identifying and reporting brucellosis infection. This requires physicians to be aware of patients at high-risk for disease and a high degree of suspicion to implement the proper testing and treatment.8,11

6. References 1. Franco, Maria Pia, Maximilian Mulder,Robert H Gilman, and Henk L Smits. "Human brucellosis." Lancet Infect Dis. 7. (2007): 775-786. 2. Memish, Ziad, Manuel Mah, Suliman Al

Mahmoud, Mohammad Al Shaalan, and M Yousuf Khan. "Brucella Bacteraemia: Clinical and Laboratory Observations in 160 Patients." Journal of Infection. 40. (2000): 59-63. Troy, Stephanie, Leland Rickman, and Charles Davis. "Brucellosis in San Diego." Medicine. 84.3 (2005): 174-187. Jacob, Nestor, Claudia Rodriguez, Maria Bingaghi, Pablo Scapellato, Maria Rosales Ostriz, Sandra Ayala, and Nidia Lucero. "Brucellosis complicating chronic noninfectious disorders: diagnostic and therapeutic dilemmas." Journal of Medical Microbiology. 57.9 (2008): 1161-1166. Center for Disease Control. Brucellosis. < http://www.cdc.gov/brucellosis/index. html>. Updated 11/12/2012. Center for Disease Control. Summary of Notifiable Disease. 2009. <http://www. cdc.gov/mmwr/preview/mmwrhtml/ mm5853a1.htm?s_cid=mm5853a1_w>. Updated 5/13/2011. Wise RI. “Brucellosis in the United States. Past, present and future.” JAMA. 244.

(1980):2318-22. Sauret, John, and Natalia Vilissova. "Human brucellosis."Journal of American Board of Family Medicine. 15.5 (2002). 9. Jacob, Nestor, Claudia Rodriguez, Maria Bingaghi, Pablo Scapellato, Maria Rosales Ostriz, Sandra Ayala, and Nidia Lucero. "Brucellosis complicating chronic noninfectious disorders: diagnostic and therapeutic dilemmas." Journal of Medical Microbiology. 57.9 (2008): 1161-1166. 10. Skalsky, Keren, Dafna Yahav, Jihad Bishara, Silvio Pitlik, Leonard Leibovici, and Mical Paul. "Treatment of human brucellosis: systematic review and meta-analysis of randomised controlled trials." BMJ. 336. (2008): 701. 11. Araj, George F. “Update on Laboratory Diagnosis of Human Brucellosis.” International Journal of Antimicrobial Agent. 36. (2010): 12-17. 8.

Missouri Family Physician April - June 2014

MAFP Members in the News/FMCC

Members in the News The Association of Family Medicine Residency Directors (AFMRD) installed Todd Shaffer, MD, MBA, FAAFP, professor and director of the UMKC School of Medicine’s Community and Family Medicine Residency Program, as president on March 30 during its annual business session at the National Program Directors Workshop in Kansas City, MO. Shaffer has been a board member of AFMRD for the past five years, serving as its treasurer and most recently as president elect. He has also received AFMRD’s “Gold Level Program Director Recognition Award.” Peter Koopman, MD (Columbia) and William Fish, MD (Lake Ozark) attended the Multi-State Forum which was held February 28-March 1, 2014 in Dallas, TX. The Iowa Academy of Family Physicians was the hosting chapter. The Family Medicine Congressional Conference was held April 7- 8, 2014, in

Pictured above, left to right: Michael Tuggy, MD, Todd Shaffer, MD, and Grant Hoekzema, MD.

Washington, DC. More than 200 physicians attended the meeting. MAFP physician members who attended include: Emily Doucette, MD (Columbia); Peter Koopman, MD (Columbia); Keith Ratcliff, MD (Washington); Ingrid Taylor, MD (Clayton); and Todd Shaffer, MD (Lee's Summit). Sponsored by the American Academy

of Family Physicians and the Council of Academic Family Medicine, the conference educates participants on family medicine’s legislative priority issues, trains attendees on how to educate lawmakers on Capitol Hill, and allows participants to put these skills to use with federal legislators and their staff. Advocacy is a high priority of AAFP and the CAFM organizations. As part of the meeting, MAFP participants had the opportunity to meet with Representatives Vicky Hartzler, Blaine Luetkemeyer, Lacy Clay, and Sam Graves as well as Sen. Roy Blunt and representatives from Sen. Claire McCaskill's office to urge passage of legislation that will maintain access to care for elderly and disabled Americans. Such legislation would also address the primary care physician shortage by supporting primary care medical education as well as medical school scholarship and loan repayment programs. [Pictured on the front cover, left to right: Peter Koopman, MD, Emily Doucette, MD, Shelly Andrievk, RN-BC, BSN, Ingrid Taylor, MD, Todd Shaffer, MD, and Keith Ratcliff, MD.]

FMCC participants pictured above, L to R: Ingrid Taylor, MD; Shelly Andrievk, RN; Todd Shaffer, MD; Julia Latash, health legislative liaison with Sen. McCaskill; Peter Koopman, MD; Emily Doucette, MD; and Keith Ratcliff, MD.

MAFP Advocacy Day participants are pictured above with Keith Frederick, DO, State Representative for the 121st District (middle) on February 25, 2014.

Pictured above, L to R: Emily Doucette, MD; Rep. Lacy Clay; and Ingrid Taylor, MD at Capitol Hill on April 8, 2014 in conjunction with the Family Medicine Congressional Conference.

Pictured above are MAFP board members and guests who attended the February 25 board meeting at Capital Plaza Hotel in Jefferson City

16 Missouri Family Physician April - June 2014

Advocacy Day/Physician of the Year Nominees MAFP

4th Annual Advocacy Day On February 25, 2014, all participating physicians and those advocating for issues facing family medicine brought their experiences and enthusiasm with them to the State Capitol for MAFP's 4th Advocacy Day. Attendees shared MAFP's priority issues and stances on pending legislation with their legislators. MAFP distributed desk-size first aid kits to the legislative offices which were personalized with the MAFP logo. On March 5, MAFP members also participated in the Missouri Tort Reform Coalitionâ&#x20AC;&#x2122;s White Coat Day to advocate for passage of legislation to reinstate the cap on non-economic damages in medical malpractice cases. It was a very busy legislative session for family medicine issues. Both the Senate and House debated issues relating to tort

2014 MAFP Family Physician of the Year Nominees Congratulations to Missouri's 2014 Family Physician of the Year Award Nominees. The award winner will be selected by the MAFP Member Services Commission and honored at the Annual Scientific Assembly in June at the Lodge of Four Seasons, Lake Ozark, MO. Theodore Baldwin, MD - Excelsior Springs George Carr, MD - Jefferson City

reform, Medicaid expansion, and bills regarding APRNS, Physician Assistants and vaccines, to name a few. MAFP would like to thank Arthur Freeland, MD, and Keith Ratcliff, MD, MAFP Advocacy Commission Co-Chairs, and Pat Strader, MAFP Government Consultant, for their efforts in organizing MAFPâ&#x20AC;&#x2122;s issues and viewpoints. MAFP would also like to recognize members who took time away from their schedules to attend the hearings and volunteered to testify on legislation during the 2014 legislative session. Members include: William Fish, MD; Keith Ratcliff, MD; and Nina Kiekhaefer, MD. MAFP would also like to especially thank the following dedicated advocates of family medicine who took time away from their busy schedules to visit the State Capitol on February 25.

2014 Participants Imani Anwisye, MD (St. Louis) Emily Doucette, MD (Columbia) Kathleen Eubanks-Meng, DO (Blue Springs) Bill Fish, MD (Lake Ozark) Gena Gardiner, MD (St. Louis) Peter Koopman, MD (Columbia) Kate Lichtenberg, DO (Kirkwood) Lisa Mayes, DO (Macon) John Paulson, DO, PhD (Joplin) Jenny Powell, MD (Lebanon) Jonathan Privett, MD (Piedmont) Daniel Purdom, MD (Liberty) Keith Ratcliff, MD (Washington) Mark Schabbing, MD (Perryville) David Schneider, MD (St. Louis) Walt Sumner, MD (Webster Groves) Jamie Ulbrich, MD (Marshall)

Dr. Baldwin

Dr. Carr

Dr. Guss

Dr. Halverson

Dr. Harris

Dr. Legler

Dr. O'Brien

Dr. Powell

Dr. Pulliam

David Guss, MD - Washington Larry Halverson, MD - Springfield Louis Harris, MD - Bolivar Larry Legler, MD - Independence John O'Brien, MD - Weldon Spring Jennifer Powell, MD - Osage Beach David Pulliam, DO - Higginsville

Missouri Family Physician April - June 2014

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18 Missouri Family Physician April - June 2014

Tar Wars MAFP

Tar Wars Program continues to make a difference in Missouri schools

Today

MAFP would like to thank those who took time out of their busy schedules to present Tar Wars at a local school. It really does make a difference. A County Health Nurse who has been presenting Tar Wars for several years recently stated, “Just an FYI, after our presentation at one of the schools this year – the teacher told me that he quit after the presentation last year. He said that he wanted to be able to set a good example for his students, and that Tar Wars was one of the deciding factors that help him quit. Things like this make it all worth it!” Additional quotes from Teacher Surveys from 2013-2014 Tar Wars presentations are included below.

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

"When materials are supplied, it is easier to follow through with the program." "The presenters were flexible and engaged all students." "This was my first year with this program - really enjoyed it and can't think of anything to improve it. Kids are still talking about the program!" "They get to 'see' the negative effects - not just hear about them." "The handouts were helpful and helped keep students engaged . . . I don't know what it would be like without them or if we could afford it?"

www.tarwars.org

There is no cost to the school or presenter. Toolkits are mailed to the presenter or the school and include: • All handouts for students and parents • Tobacco advertisements and straws for interactive activities • Wristbands and pencils to be used as prizes • Poster board So, what are you waiting for? Present Tar Wars during the upcoming 2014-2015 school year! For more information, contact Nancy Griffin at (573) 635-0830 or email: ngriffin@mo-afp.org.

Supported in part by a grant from the American Academy of Family Physicians Foundation.

Missouri Family Physician April - June 2014 TW hlf vert.10.indd 1

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