Mafp magazine oct dec 2012 final for web

MISSOURI

Official Publication of the Missouri Academy of Family Physicians

Family Physician

OCT − DEC 2012 Volume 31, Issue 4

Jamison Liles 2012 Tar Wars Poster Contest Winner pg. 8

Resident Grand Rounds Vanessa Ren, MD pg. 14 FM Residency Program Composites pg. 22-27

contents MAFP

Mark your Executive Commission Board Chair - Todd Shaffer, MD, MBA (Lee’s Summit) President - Kate Lichtenberg, DO, MPH (Kirkwood) President-elect - Bill Fish, MD (Liberty) Vice President - Daniel Purdom, MD (Independence) 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: 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: Kathleen Eubanks-Meng, DO

Director: George Harris, MD, MS

Alternate: Vacant District 8 Director: Mark Woods, MD

Director: John Paulson, DO, PhD

Alternate: Vacant District 9 Director: Charlie Rasmussen, DO

Alternate: Vacant District 10 Director: Mark Schabbing, MD

Alternate: Steven Douglas, MD Resident Directors Suzan "Annie" Lewis, DO Imani Anwisye, MD (Alternate) Student Directors David Kramer Amanda Williams (Alternate) AAFP Delegates Bruce Preston, MD Larry Rues, MD Darryl Nelson, MD (Alternate)

Calendar

20th Annual Fall Conference & SAM Working Group Big Cedar Lodge, Ridgedale, MO November 9-11, 2012

AAFP ALF/NCSC Kansas City, MO April 25-27, 2013

3rd Annual Advocacy Day State Capitol, Jefferson City, MO February 26, 2013

65th Annual Scientific Assembly The Lodge of Four Seasons, Lake Ozark, MO June 7-9, 2013

Save the date!

Advocacy Day February 26, 2013 State Capitol Jefferson City

Inside this issue 4 Disaster Preparedness Across the State

20

Awards Caps are Gone. Is Your Malpractice Insurance Ready?

James R. Cantalin, JD

5

How Does ObamaCare Affect Us?

22

Residency Programs

6

Externship Experience

Kate Lichtenberg, DO, MPH, FAAFP

8

Arthur Freeland, MD, FAAFP

Advertisements

William Otto, Student, SLU Ontario Lacey, Student, MU

State Tar Wars Poster Winners

10 Members in the News

2

Cox Health

4

Annual Fall Conference

8

Family Physicians Inquiry Network

9

Professional Solutions Insurance

MAFP Staff Executive Director - Jennifer Bauer Education & Finance Director - Nancy Griffin Managing Editor/Member Services - Laurie Bernskoetter

11 Nominate 2013 Family Physician of the Year 12 Help Desk Answers

11 Bristol Manor

Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101

14 Resident Grand Rounds

19 Physicians Professional Indemnity

Association

p (573) 635-0830 www.mo-afp.org

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

Resident Case Studies

11 Wellpoint 13 ProAssurance Group

Vanessa Ren, MD

16 Student Case Report

21 HEALTHeCAREERS

An Duc Pham, MS-V

18 Education Gaps Between FPs and NPs 2012 Annals of Family Medicine

25 Core Content Review 28 Missouri Professionals Mutual

Missouri Family Physician October - December 2012 3

MAFP disaster preparedness

Disaster Preparedness Across the State Kate Lichtenberg, DO, MPH, FAAFP 2012-2013 MAFP President

A

s we approached the one year anniversary of the F-5 tornado in Joplin last May, we brought you information about how you could better prepare yourself and family for disaster and how to prepare your practice for disaster and dealing with the aftermath. Some may be interested in doing more.

The Missouri Disaster Response Systems (MoDRS) covers a wide array of response types. From the immediate and rapid response to the sustained deployments; from the unexpected, to the annual well planned events, those groups are able to respond to just about anything. Family physicians are well equipped to assist in all aspects of medical care and having physicians who are familiar with patients of all ages is critical for disaster care.

MoDRS is a 501c nonprofit corporation that may be activated by the State Emergency Management Agency (SEMA) either for a disaster requiring medical response or for scheduled events such as a state fair or airshow.

The Missouri-1 Disaster Medical Assistance Team (MO-1 DMAT) is often confused with MoDRS although they are very similar. The MO-1 DMAT is a federal medical response team that is activated through the National Disaster Medical System (NDMS) under the US Department of Health and Human Services.

Opportunities exist to volunteer with either of these groups. If you are interested in serving with MoDRS, please contact Jill Thorp at jthorp@modrs.org. If you would like

additional information about serving with MO-1 DMAT, please visit www.ndms.dhhs.gov.

I think we are all hopeful that we will never have to recover from an F-5 tornado again. However, there is some comfort that the men and women who volunteered their time and expertise are there to help when called upon again Special thanks to Paula Nickelson, Health Care Systems Preparedness Planner, Center for Emergency Response and Terrorism, Division of Community and Public Health, Missouri Department of Health and Senior Services, for her assistance with providing disaster planning information for the series of articles.

Register online it's

Do you need

CME?

easy!

Join us for the 20th Annual Fall Conference and SAM Study Group www.bigcedar.com

Visit www.mo-afp.org • Registration Form • Room Reservation Form • Schedule of Events 4 Missouri Family Physician October - December 2012

to be held at Big Cedar Lodge, Ridgedale, Missouri

November 9-11, 2012

how does obamacare affect us MAFP

How Does ObamaCare Affect Us? Arthur Freeland, MD, FAAFP 2012-2013 MAFP Advocacy Commission Co-Chair

T

he “Patient Protection and Affordable Care Act” passed Congress and was signed into law on March 23, 2010. It is the type of compromise that really doesn’t completely satisfy anyone on either side of the aisle, leaving lots of room for improvement. Now that it has passed the Supreme Court challenge largely intact, it is important that we, the Family Physicians of America, seek to understand and work constructively with its tenets. Some parts of it took effect immediately, many others in the first 6 to 12 months. Some clauses don’t take effect completely for several years.

Some significant benefits to primary care providers including Family Physicians are: • Medicare reimbursement for Primary Care services was increased by 10% on January 1, 2011.

• Medicaid reimbursement for primary care services increases to match Medicare allowables on January 1, 2013.

• It mandates the coordination of care of certain Medicaid patients by a primary care physician through “Health Homes” and similarly for Medicare patients in Medical Home practices.

• All health plans must cover without copay all preventive measures judged effective by the Preventive Services Task Force.

Many of the best accepted clauses of the act have to do with insurance reform. No longer can someone be refused coverage due to a “pre-existing condition,” nor cancelled due to

contracting a high-risk illness such as cancer (known as “rescission”). In fact, premiums can only vary due to age, family composition, geographic location and tobacco use. There can no longer be “lifetime caps” on expenditures for a given patient.

With individual policies, 80% of premiums have to be spent on medical care. If more than 20% is spent on administration and overhead, the difference has to be refunded to the patient. For large groups that number is 85%. Some insureds have already received rebates from 2011. Also, deductibles will be limited to $2,000 per individual, $4,000 per family.

Special low cost “catastrophic” policies will be available to those age 30 or below.

The insurance marketplace will change dramatically. Multistate “compacts” will allow insurance products to be sold across state lines, increasing competition. The Act provides for insurance “exchanges” where cost, data (such as percentage of claims denied), enrollee rights, cost sharing requirements, details of provider networks (i.e. Is my doctor on this plan?) are available in transparent fashion. Dependents up to age 26 can already remain on their parents plan (this has dropped the ranks of the uninsured significantly all by itself!).

There will be uniformity of plans (to make comparison shopping easier) and uniformity of the claims process (making physician billing much easier).

These are the things that will affect us as Family Physicians the earliest and most directly, but there is much, much, much more in the Act. I have found the best summary

one could imagine, both of the “Affordable Care Act” and of the problems with our health care system it was meant to address, in Dr. Ted Epperly’s book Fractured, America’s Broken Health Care System and What We Must Do to Heal It. He does a great job not only of detailing what is in the Act, but also the history of health care organization in the US, contrasted with how many other countries accomplish the provision of health care. He finishes with the problems that have yet to be addressed. If you are interested in the organization of health care delivery and especially in learning what the ACA does, please consider reading at least the chapter on the ACA beginning on page 185

Send us your news!

The Missouri Family Physician magazine welcomes your input. If you have "Members in the news" information you would like to share and include in the next issue, please submit newsworthy items for review to: lbernskoetter@mo-afp.org. See page 10 for current news about your colleagues.

Missouri Family Physician October - December 2012 5

MAFP externship FHFM externship experience experience

Family Health Foundation of Missouri Offers Clinical Opportunties & Experience From May 18 to June 15, I participated in the summer externship program sponsored by the AAFP Foundation and the William Otto, Student Family Health Saint Louis University Foundation School of Medicine of Missouri (FHFM). I completed my externship at the Mercy Family Medicine Residency Program in St. Louis, MO. The majority of my externship was completed at the residency program’s outpatient clinic, where I worked with Ms. Kristin South, the Residency Program Coordinator for Mercy Family Medicine.

As an academic institution, the clinic had both faculty and resident physicians, and I was able to work with a wide range of physicians. That was one of the most useful parts of the externship; I was able to observe how many different physicians assess and treat patients, and I was able to pick up many different tips and tricks that would not have been possible if I had only worked with one physician.

My roles within the treatment process varied depending on the physicians that I worked with. Some of the physicians, perhaps remembering their years in medical school, worked hard to ensure that I was involved in the clinical process. I was able to take the history of present illness and discuss current issues, perform rudimentary physical exams, and participate in the diagnosis and assessment of the patient. I was often responsible for seeing the patient and presenting the case to the physician; we would then discuss the case before visiting the patient together. Though I was not

Founded in 1988 by the Missouri Academy of Family Physicians as its philanthropic arm, the Family Health Foundation of Missouri, (FHFM) is dedicated to improving the health of Missouri families by supporting scientific, educational, and charitable activities through the field of Family Medicine. With AAFP Foundation matching funds, the FHFM sponsors four-week summer externships. FHFM is a 501 (c) (3) charitable corporation and contributions are tax deductible. To donate, visit: www.mo-afp.org.

able to edit patient charts in the electronic records system, I was able view past medical history so that I could help with the diagnosis and assessment of each individual patient.

Other physicians emphasized observation of the clinical process. We would see the patients together, and I would watch to see how they interacted with the patient and performed the physical exam. Then, after resolving the problem and finishing the appointment, the physician and I would discuss the patient and work through the assessment and treatment plan. It was always fascinating to me to view how others would approach a problem and then compare it to my assessment and plan.

Of course, my involvement in the treatment process was always dependent on the discretion of each individual patient. As I got more familiar with the individual physicians that I worked with, I was often able to predict how many patients I would be able to see based on their patient population. Many a time I would be required to wait in the office as the physician visited with a patient. I found this to be especially true for female patients in for gynecological exams, as they were uncomfortable allowing a male medical student to view the exam.

One aspect of my externship that I appreciated was how the faculty and residents worked very hard to ensure that I was able to assist with – and eventually perform – basic procedures. There were always two or three other medical students at the clinic, so I was always thankful to get my turn! I was able to assist in the excision of a thrombosed external hemorrhoid and in the lancing and draining of an abscess. As I grew more familiar with the equipment, I was allowed to use the Doppler Monitor to assess fetal heartbeat.

Eventually, I was able to perform a full

6 Missouri Family Physician October - December 2012

ultrasound. Other times I wasn’t able to assist in the procedure but was able to observe – in this roundabout fashion I learned the proper landmarks and approaches for joint injections. Given that there were always plenty of willing medical students to help with procedures, I was especially thankful that I was able to help with any procedures.

One day each week, I attended grand rounds with the Family Medicine inpatient service at Mercy Medical Center before returning to the clinic to see patients .

There we learned about diverse topics such as developing asthma action plans or how to properly prepare a palliative care plan for patients who required one. Other times, the residents developed and presented Morbidity and Mortality case reports about interesting cases that they had worked on.

I was also responsible for attending the same didactic lectures that the interns and residents attended, where we learned about pharmaceutical management of hypertension, the proper delivery techniques, or the diagnosis and treatment of injuries to the hand and wrist. Professional development was also a major component of these lectures, as we discussed what aspects of medicine were important to us and how to ensure that our future practices exemplified those qualities. I greatly enjoyed those lectures, as it allowed me to discern what was truly important to me in treating and caring for patients.

My four-week rotation at Mercy Family Medicine was really valuable to me. The clinical experiences that I was able to gain during my externship will only benefit me as I continue my medical education.

Many of my classmates were jealous when they learned of how involved I was in the clinical process and how much I was able to learn during my short rotation. I am certain that the externship will give

>>

externship experience FHFM First, I would like to say thank you to the staff at the Missouri Academy of Family Physicians (MAFP) and Family Health Foundation of Missouri (FHFM) for accepting Ontario Lacey, Student University of Missouri my application School of Medicine to participate in the 2012 summer externship program. My name is Ontario Lacey and I am now a secondyear medical student at the University of Missouri - Columbia School of Medicine.

My experience this summer in being involved with the MAFP/FHFM summer medical student externship program was the best and most fulfilling experience professionally in my life. It was absolutely a great experience, and I learned a considerable amount about medicine. The breadth of procedures and patients I saw in the 45 days of my externship tenure was exactly what I expected medicine to be like.

I saw infants from 2-months old to elderly patients up to 75. I saw numerous prenatal patients whose care included physicians performing pregnancy tests or seeing women at 39 weeks and 5 days. Needless to say, I became quite comfortable at measuring fetus size using the McDonald’s rule and finding the fetus heartbeat using

>>

me a bit of a head start over my fellow students, especially when we start our clinical years.

I am also very thankful to the faculty and residents at Mercy Family Medicine.

They were always willing to answer any of my questions or to help me reason through a complicated clinical problem. The residents were constantly giving me tips on how to succeed during medical school and the internship year, and the faculty physicians strived to ensure that I was truly comprehending what I was observing. One faculty member stayed with me for an extra hour and worked through the finer points of a knee exam. I really appreciated how all of the physicians sought to involve me in

a fetal heart monitor. I saw and diagnosed diseases ranging from coarctation of the aorta, mononucleosis, cystic fibrosis, hypertension and diabetes. These are just a few of the procedures that I performed and diseases that were diagnosed.

The residents in which I worked under became fully comfortable with me seeing patients before they saw them. They treated me as a resident in training. I appreciated their confidence in me, and it made me work hard to keep their trust. On a normal day at the clinic, I would typically get the patient’s history from the nurse, and ask the resident if it was alright if I saw the patient. Then, I would proceed to enter the room in which the patient was waiting in, and do what I had been trained to do in my first year of medical school. I will admit, they do prepare us very well to see patients early and often at the University of Missouri - Columbia School of Medicine.

I will pause here to mention that most of my one-on-one patient interaction was in a clinical setting (75%). I worked out of the Family Health Center in Columbia, Missouri. I also worked in the MEDZOU health clinic one night a week for a month to provide care for uninsured patients. The rest of of my time was spent performing rounds with the Family Medicine team at the University of Missouri Hospital in Columbia, MO. The schedule, as provided by my preceptor and mentor, gave me the best of both worlds (clinic versus hospital).

I would have to say that I enjoyed the clinic

setup much more. The reason being is that it allowed for more hands-on training.

However, the hospital setting allowed us to really treat the more severe cases.

To cap the program off, MAFP invited me to attend a three-day family medicine conference at the Lake of the Ozarks. At the conference, we discussed upcoming issues and procedures in family medicine.

There were three days of seminars in which you may attend to gain knowledge in a vast array of health topics. Also, some of the participants who had performed research presented their research in the form of a poster presentation/contest with prizes for the top three posters.

In closing, I would like to state that this experience would be beneficial to any medical school student, and I feel I have gained an advantage by taking part in this program. I feel this program is a “diamond in the rough” and deserves better participation. Again, thank you MAFP for a wonderful summer experience!

the clinical process, even though my overall lack of medical knowledge meant that they spent a lot of time explaining their thought process.

When I applied for the externship program, I knew very little about the discipline of Family Medicine. As a child, I always saw a pediatrician, and I switched to an internist when I became an adult. I was always interested in primary care, but I did not have a full appreciation for the full breadth of family medicine. For example, I was surprised that some of the physicians at Mercy Family Medicine cared for pregnant patients. This externship program was crucial in exposing me to a different aspect of primary care. Now, I have a much greater

appreciation for the discipline of Family Medicine and all that it entails, and am seriously considering Family Medicine as a possible career path.

As I continue my medical education, I will definitely recommend this externship program, as well as other clinical opportunities. I will also continue to consider a Family Medicine residency.

Family Medicine is such a broad discipline, and this externship was a great opportunity for me to experience the various aspects of Family Medicine while also building up clinical knowledge and experience that will only help me as I continue my medical education

MAFP (through the AAFP Foundation and FHFM) offers summer externships each year. Information will available on our website and emailed to medical schools in January.

Visit www.mo-afp.org and click on the "Family Health Foundation" tab and then "Externships".

For more information, or to donate please contact Nancy Griffin at ngriffin@mo-afp.org.

Missouri Family Physician October - December 2012 7

MAFP tar wars

State Tar Wars Poster Winners Honored What is Tar Wars?

Tar Wars is a school-based tobacco-free education program for fourth-and fifth-grade students in your community that: • Gets children thinking and talking about the short-term effects and image-based consequences of tobacco use • Explains how the tobacco industry specifically targets kids in advertising and other media • Talks about the costs associated with using tobacco products Who can present Tar Wars?

Family physicians, residents, medical students, school nurses, nurse practitioners, physician assistants, and other health care providers, community leaders and parents are encouraged to present Tar Wars.

Governor Jeremiah "Jay" Nixon recognized Tar Wars week with a proclamation signing in his office at the State Capitol on September 25, 2012. Pictured above (left to right) are Jamison Liles, Governor Jay Nixon, Sophie Richards, and Brandi Berkstresser.

2012 Missouri Tar Wars poster winners included: 1st Place - Jamison Liles Craig R-3, Craig, MO 2nd Place (tie) - Brandi Berkstresser Greenwood Elementary, Lake Winnebago, MO 2nd Place (tie) - Desiree Hufford Mound City R-2, Mound City, MO 4th Place - Timothy Schweizer Sunny Point Elementary, Blue Springs, MO 5th Place - Sophie Richards South Holt R-1, Oregon, MO 2012 Tar Wars National Conference Jamison Liles, the Missouri first place poster winner traveled to Washington, DC July 16-17 to participate in the Tar Wars National Conference. At the 2012 Tar Wars National Conference, the poster winners and their families visited with legislators to advocate for tobacco-free issues and family medicine.

8 Missouri Family Physician October - December 2012

Tar Wars Mission To educate students about being tobacco-free, provide them with the tools to make positive health decisions, and promote personal responsibility for their well-being.

Tar Wars 25th Silver Anniversary Celebration Tar Wars will be celebrating its 25th anniversary in 2013. The 25th anniversary kickoff, which began at the national conference in July, will commemorate and highlight the history of the Tar Wars program, celebrate accomplishments, and raise awareness of the program with family physicians and others, as well as expand the reach of the program into underserved areas during the 25th anniversary.

MAFP MEMBERs in the news Betsy Garrett, MD, Columbia, MO, was selected by the AAFP Board of Directors as the recipient of the 2012 AAFP Thomas W. Johnson Award which will be presented on October 17 during the 2012 Congress of Delegates in Philadelphia. The award is the highest honor presented by the Academy for outstanding contributions to family medicine education in undergraduate, graduate, and continuing education spheres.

Betsy Garrett, MD

David Cathcart, MD, Camdenton, MO, was recognized as the Lake Sun 2012 Reader's Choice Award Winner as the #1 Family Physician at the Lake during the 19th annual Best of the Best Reader's Choice Awards conducted by the regional newspaper, Sun Lake Leader.

In September, George Harris, MD, Kansas David Cathcart, MD City, MO, was chosen as a member of the Society of Teachers of Family Medicine (STFM) National Clerkship Curriculum Editorial Board (Leawood, KS).

The STFM Education Committee has been tasked with overseeing this board whose responsibilities include planning goals and priorities for the curriculum and website.

George Harris, MD

On August 14, 2012 ,Vicki Roberts, MD of Sikeston, MO and her staff at Family Medicine of Southeast Missouri (FMSEMO) participated in a training program held at their office to become members of the GO Diabetes Master Clinician Program (GODMCP). The practice is one of only 4 programs selected to receive this honor. Other practices are located in Oklahoma, Illinois and North Carolina. The education and training is provided by the Florida Academy of Family Physicians Foundation through its medical director Edward Shahady, MD. The program is part of the Georgia and Oklahoma Academies GO Diabetes Program that is supported by an educational grant from Sanofi Aventis.

Pictured left to right: Barbara Mickel, FNP, Blinda Nelson, Sandra Murphy, Tomisha Wiley, Tonia Baker, Vicki Roberts, MD and Ed Shahady, MD. 10 Missouri Family Physician October - December 2012

Ed Kraemer, MD, Lee's Summit, MO, was awarded the "MoCAN Healthcare Professional Award - Excellence in Connecting Health to the Community" regarding his leadership and ongoing work in the Livable Streets (bicycle/walking friendly) initiative in Lee's Summit. The Missouri Council for Activity and Nutrition (MoCAN's) Healthcare Workgroup seeks to recognize a healthcare professional who has Ed Kraemer, MD demonstrated leadership in promoting an active living, healthy eating or other obesity prevention initiatives in his/her community.

On October 2, AAFP announced that Julie K. Wood, MD, Lee's Summit, MO, accepted the position of Vice President for Health of the Public and Interprofessional Activities as of January 1, 2013. The Vice President provides vision and strategic direction, as well as oversight for the Health of the Public and Science mission area., coordinates AAFP interprofessional interactions and collaborations with medical organizations Julie K. Wood, MD in the United States and around the world., and oversees the international activities of the AAFP. The Vice President will also serve as a key member of the AAFP's executive leadership team.

Elizabeth Keegan Garrett, MD, St. Louis, MO, was awarded the 2012 Pfizer Teacher Development Award on September 12 during a reception held at Saint Louis University. Dr. Keegan Garrett is one of thirteen community-based physicians, practicing less than 7 years, from across the country, honored by the AAFP Foundation for her commitment to education in the field of family medicine. The Pfizer Teacher Development Awards Program recognizes outstanding, community-based family physicians combining clinical practice with part-time teaching of family medicine. This program is supported by a grant from Pfizer, Inc. Pictured below, left to right are F. David Schneider, MD (Department Chair and Professor), Elizabeth Keegan Garrett, MD, and Christine Jacobs, MD.

nominate family physician of the year MAFP

Nominate the 2013 MAFP Family Physician of the Year Do you have an outstanding, caring colleague or physician in your community that deserves the title “Missouri Family Physician of the Year?"

The Missouri Academy of Family Physicians (MAFP) supports over 1,100 active members in the work-force ~ doing extraordinary things every day. You know them, and we would like to acknowledge them.

MAFP is now seeking nominations for this prestigious award.

Nominate your family physician or a family physician that you know!

Nominations may be made by any member of the MAFP or the public.

Visit our website at www.mo-afp.org to find everything you need: • Nomination Form • Nomination & Selection Process • Past Winners • Judging Criteria • Eligibility Requirements & Limitations You may also request information by calling MAFP at (573) 6350830 or by emailing lbernskoetter@mo-afp.org .

The winner will be honored at the MAFP Annual Meeting in June 2013.

(Mail, fax, e-mail or online submissions are accepted)

Nominations due by March 1, 2013

Missouri Family Physician October - December 2012 11

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!

July 2012 EBP

12 Missouri Family Physician October - December 2012

Missouri Family Physician October - December 2012 13

MAFP resident grand rounds

Neurofibromatosis: Counseling Issues and Considerations for the Obstetrical Patient Vanessa Ren, MD, PGY2 Research Family Medicine Residency Program Kansas City, MO Introduction Neurofibromatosis (NF) is a mutation of a tumor suppressor gene, resulting in peripheral nerve tumors which can rapidly proliferate and cause significant morbidity and mortality. It has a prevalence of 1:3000-1:5000 patients1 and while there is 100% penetrance, there is a wide range of expressivity which can make diagnosis challenging (see Table 1). Indeed, many of the stereotypical features are age dependent and may not present until the patient experiences a hormonal surge (such as puberty or pregnancy). It is not uncommon for patients to be diagnosed late in life or to be lost to follow up. As patients with NF are at significant risk for complications secondary to their disease, proper counseling and routine health maintenance are vital to their care. This is especially true for the obstetrical patient, who is at risk for both vascular and anatomical complications during pregnancy. Compared to the general obstetrical population, NF patients are more likely to experience first trimester miscarriage, stillbirth, higher C-section rates, IUGR, transient hypertension of pregnancy, and maternal mortality.2,3 Neurofibromatosis in the Obstetrical Patient Neurofibromas have been shown to worsen in size and number in response to hormones. In one study, four out of five NF tumors were positive for growth hormone1, and 75% carried progesterone receptors (estrogen receptors were also present, though in less quantity).4 Frequently, it is not the pregnancy that brings a patient to the office, but the presence of worsening symptoms. Therefore, the family physician may be the first to provide obstetrical evaluation to these patients. Counseling

for the NF patient includes both a genetic review, as well as a discussion of the potential complications of pregnancy.

It is important for NF patients to understand the risk of passing the disease to their children. Although 50% of NF is caused by a spontaneous mutation,5 it is passed in an Autosomal Dominant fashion.

Assuming only one parent is affected, any child has a 50% chance of contracting the disease. The severity of the parent’s disease has no effect on the potential manifestations of the child, and, therefore, genetic counseling is important for NF patients regardless of when they present to clinic.

The increases in neurofibromas that occur during pregnancy are understandably upsetting to the patient. Although cutaneous manifestations cause the majority of patient stress, it is vital to remember that all tumors, both superficial and visceral, can be affected by the hormone surge. In the non-pregnant NF population, 5-13% of patients will experience malignant tumors (which is also the primary cause of mortality in NF patients).1 Therefore, it is reasonable to consider patients with prior malignancy to be extremely high risk which need both OB/GYN and neurology referrals. These patients may warrant a pre-conception MRI of the trunk and abdomen in order to evaluate for pre-existing Schwannomas.1 Some specialists recommend that women with prior malignancies do not become pregnant due to the risk of rapid and often fatal transformation of malignant tumors.

Even in patients without history of malignancy, a pre-conception pelvic and chest x-ray is justified.2 This is in order

14 Missouri Family Physician October - December 2012

Vanessa Ren, MD

to establish the existence of pelvic and thoracic masses. Growth of visceral/ pelvic tumors can result in dystocia and significant pain. There is also an increased rate of cephalopelvic disproportion and malpresentations secondary to pelvic tumors.2 As these tumors increase in size they can ultimately have necrosis or significant internal bleeding which can result in hemorrhage and/or anemia.2,6 Other potential complications include epidural failure due to the presence of spinal tumors and difficult C-Sections due to pelvic masses.

While enlarging tumors are easy to diagnose and monitor, hypertension is a more insidious complication for these patients. HTN is caused by three primary causes in NF patients: renal artery stenosis (a common finding in NF), pheochromocytoma (occurs in 1-5% of NF patients), and catecholamine-secreting nodular neurofibromas.1 NF patients are therefore prone to HTN, but the incidence of HTN increases significantly with pregnancy (In one study, 19 pregnancies complicated by NF1 were reviewed, and all patients had an increased BP from first prenatal visit to term).7 The HTN of pregnancy in NF is thought to be secondary to vascular complications. Pathologic uterine examinations have shown thickening and marked tortuosity of the spiral arterioles, as well as an increase in both smooth muscle and elastic fibers in uterine vessel walls.7,8 It is hypothesized that the affected vessels cannot tolerate the increased blood volume during pregnancy, and, therefore, result in HTN. Unlike pre-eclampsia, HTN can develop at any time during an NF pregnancy.

resident grand rounds MAFP Of particular concern is the potential for NF patients to develop other kinds of tumors, particularly pheochromocytoma.5 It is not known if pregnant NF patients are at increased risk of developing pheochromocytoma, but its development during pregnancy carries a 50% fatality rate.5 Therefore, pregnant patients require more frequent BP checks. Patients should be taught to check their BPs at home, and any fluctuating course of pressure readings should be rapidly evaluated for pheochromocytoma.2 NF pregnancies also carry a high risk of IUGR.2,3,9 As previously mentioned, NF patients appear to have abnormal uterine and placental vessels, which may be the contributing factor. In one case review of five clinic patients with NF1 that had IUGR, the placentas were all small for gestational age and three displayed small areas of infarction. In light of the high incidence of IUGR, more frequent ultrasounds to monitor developmental progression are justified, as well as biophysical profiles in the third trimester.

There are several elements to add to the routine OB visit for these patients. In light of the increased risk of malignancy, every NF patient should have a brief neurological evaluation during regular visits. Any change in neurological status should be evaluated

as soon as possible in the clinical setting.6,10 The most common symptoms of malignant change include rapid tumor growth, pain, and onset of rapid neurological deficits.

As NF patients are also at increased risk of developing acoustic neuromas and optic gliomas, they should be briefly evaluated for HA, imbalance or hearing loss at routine visits.1,2 As previously mentioned, patients will need more frequent OB monitoring for BP checks or be reliable enough to check their BPs at home on a frequent basis.

Many patients desire birth control following delivery. Birth control recommendations should follow standard recommendations in regard to breast feeding, smoking status, etc. However, as neurofibromas carry progesterone and estrogen receptors, birth control has the potential to worsen tumors.

Progesterone is the primary receptor, therefore it is recommended to avoid progesterone-only birth control. A trial of estrogen-containing OCPs is considered appropriate, however, with close follow up to monitor for tumor change.1,11 Patients should be reassured that tumors which worsen with pregnancy and birth control often regress.11,12 Conclusion NF patients are considered high-risk pregnancies. However, many patients go through pregnancy without the

Table 1: Required Features of NF (at least 2 out of 7 necessary for diagnosis)5: 1. At least 6 cafĂŠ au lait spots 2. Axillary or inguinal freckles 3. Two or more typical neurofibromas 4. Extramedullary neurofibromas in the thoracic and lumbar regions 5. Optic Nerve Glioma 6. Two or more hamartomas (Lish Nodules) 7. Sphenoid dysplasia or typical long bone abnormalities

above complications. Therefore, it is the practitioner’s decision to refer and/or have an OB/GYN follow along in case of developing complications. Regardless of who ultimately assumes the patient’s OB care, the family physician is in an excellent position to educate his or her NF patient.

An NF patient who is well educated about her disease is her own best advocate.

References 1. Gresham DD, Braunlin JL,Vuckovich S. Caring for the pregnant woman with neurofibromatosis. MCN. 2010; 35(1): 1825.

2. Blickstein I. The obstetric perspective of neurofibromatosis. Am J Obstet Gynecol.

1988;158(2): 385-8.

3. Weissman A. Neurofibromatosis and pregnancy: an update. Journal of Reproductive Medicine. 1993; 38(11): 890-896.

4. Maldonado CP. Bilateral segmental neurofibromatosis diagnosed during pregnancy. Dermatol Online J. 2011; 17(5): 6.

5. Goldberg Y. Neurofibromatosis type 1--an update and review for the primary care pediatrician. Clin Pediatr. 1996; 35(11): 54561.

6. Nelson DB. Neurofibromatosis and pregnancy: a report of maternal cardiopulmonary compromise. Obstet Gynecol. 2010; 116(2): 507-510.

7. Belton SR. Neurofibromatosis and pregnancy: report of a case complicated by intrauterine growth retardation and oligohydramnios. Am J Obstet Gynecol. 1984; 149(4): 468-9.

8. Blickstein I. Fetal growth retardation as a complication of pregnancy in patients with neurofibromatosis. Am J Obstet Gynecol.

1987; 157(2): 343.

9. Sangwan N. Normal obstetric outcome in neurofibromatosis-1 complicating pregnancy. Journal of Medical Education & Research. 2008; 10(4): 197-8.

10. Posma E. Neurofibromatosis type 1 and pregnancy: a fatal attraction? development of malignant schwannoma during pregnancy in a patient with neurofibromatosis type 1.

BJOG. 2003; 110(5): 530-2.

11. Mautner L. Do hormonal contraceptives stimulate growth of neurofibromas? A survey of NF1 patients. BMC Cancer. 2005; 9(5): 16.

12. Edwards JN. Neurofibromatosis and severe hypertension in pregnancy. Br J Obstet Gynaecol. 1983; 90(6): 528-31.

Missouri Family Physician October - December 2012 15

MAFP case report

Should We Remove These Lipomas?

A Case Report with Associated Literature Review and Decisional Tree Benoit Blondeau, MD Department of Surgery Truman Medical Center, Kansas City, MO

An Duc Pham, MS-V University of Missouri - Kansas City

Abstract/Introduction Fascial Hernias can sometimes be difficult to diagnose if clinical suspicion is low.

Oftentimes, fascial hernias are mistaken for vascular abnormalities or soft tissue tumors. The following case report will illustrate a typical clinical course for fascial hernias. Discussion includes a literature review and a decisional tree designed to assist the clinician in diagnosis and management of fascial hernias.

history was significant only for Graves Disease and Asthma. Surgical history was positive for thyroid ablation. Patient smoked one pack of cigarettes daily for the last thirty years. He played basketball as an adolescent. Otherwise, he was in good health and had no complaints about these lesions. He did not recall when they had initially appeared.

Vignette At the general surgery clinic in an academic safety net hospital, many subcutaneous masses are observed. The generic term lipoma is used ad libitum. In most instances, the mass is indeed a lipoma.

There is one uncommon instance where the mass is, indeed, not a lipoma.

A 43-year-old man presented to Truman Medical Center Surgery Clinic for evaluation of three lipomas on his lower extremities. His primary care doctor identified the lesions and requested a surgical consultation. Two of the lesions were located on the lateral aspect of the left leg, and one on the medial aspect of the right leg (Figure 1 and 5). His past medical

Figure 1

This man was lean and muscular with no extra subcutaneous fat. On physical examination, the lesions appeared similar.

On the right leg, the bulging lesion measured approximately 1cm2 and was round. The surface was concave and smooth. Its location was on the path of the greater saphenous vein (Figure 10). On the left leg, the two lesions were located on the lateral aspect of the anterior aspect of the leg. These lesions were similar, measuring approximately 1cm2 (Figure 7,8,9).

Otherwise, circulation appeared normal and there were no skin changes. On palpation, the feeling was the same, gentle pressure of the mass would depress it. The sensation, in this lean man, of a fascial defect was appreciated on the three lesions.

Dynamic examination with flexion and extension of the ankle made the difference.

Figure 2

Figure 1: Two fascial hernias on the left leg of patient, over the anterior tibialis muscle.

Figure 2: Two fascial hernias on the left leg of patient, over the anterior tibialis muscle. Reference present shows that each lesion measures 1cm2.

Figure 3

Figure 4

With dorsiflexion, the two lesions on the left would bulge. With plantarflexion, the lesions disappeared (Figure 3 and 4). On the right, An Duc Pham, MS-V dorsiflexion and plantarflexion made the lesion bulge (Figure 5 and 6).

Based on physical exam and clinical findings, the patient was diagnosed with two fascial hernias on the lateral aspect of the left tibia and an incompetent Boyd’s perforator on the other leg. The diagnosis was explained to the patient and a report was sent to the referring physician, recommending observation.

Review of Literature A large amount of medical literature has been published regarding fascial hernias.

Some of the earliest documentation on fascial hernias was done in 1929 by Idhe. In the 1940’s, military surgeons provided accounts of muscle hernias in military recruits2,9. Since then, numerous case reports have been published in dermatological and surgical journals 1,2,3,4,6,7,9 .

Fascial hernias of the lower extremity are protrusions of muscle through a

Figure 5

Figure 6

Figure 3: Plantarflexion enhances the fascial hernias.

Figure 5: Incontinent perforator vein of great saphenous.

Figure 4: Upon dorsiflexion of left foot, the two fascial hernias seem to disappear.

Figure 6: Upon dorsiflexion, this venous bleb does not disappear.

16 Missouri Family Physician October - December 2012

case report MAFP

Figure 7

Figure 9

Figure 8

Figure 10

Figure 7: Close up view of two fascial hernias on patient’s left leg, overlying the anterior tibialis muscle.

Figure 8: Close up view of proximal fascial hernia on patient’s left leg.

Figure 9: Close up view of the distal fascial hernia on the patient’s left leg.

Figure 10: Close up view of right perforator vein over saphenous vein.

Disclosure: Patient signed a consent form that provided permission of pictures of his lower extremities to be included in a case report for academic purposes.

defect in the fascia which confines it 9. The anterior tibialis is the most commonly involved muscle 2,5,7. There are a variety of ways to classify fascial hernias. A logical approach divides fascial hernias as either spontaneous or traumatic. Spontaneous fascial hernias result from congenital defects in the fascia surrounding the muscle.

Traumatic fascial hernias can be further subdivided into direct and indirect. Direct fascial hernias would be from penetrating trauma such as a gunshot wound. Indirect fascial hernias would be due to any chronic increase in compartment pressures, such as repeated exercise.

Clinically, most fascial hernias are chronic, asymptomatic cosmetic lesions. These chronic hernias can be painful if the hernia occurs at a site of nerve perforation through the compartment fascia; the superficial peroneal nerve is commonly involved in these cases 2. Chronic fascial hernias are seen mostly in athletic young males. Fascial hernias can also be more acute, large, and symptomatic; this often is connected with a traumatic etiology 8.

The differential is quite extensive. Chronic fascial hernias can present similarly to insufficient perforator veins, arteriovenous aneurysms, lipomas, neurofibromas, and other soft tissue tumors 2. Acute muscular herniation of the leg must be differentiated from cellulitis, oesteomyelitis, thrombophlebitis, stress fractures, tumors, and shin splints 3. The decision tree, provided at the conclusion of this paper, will aid the clinician in choosing the correct diagnosis.

Diagnosis is usually based on physical exam. MRI and ultrasound have been documented to aid in diagnosis of fascial hernias 1. Aspiration has been discussed in the literature to help distinguish fascial hernias from other arteriovenous pathologies 3, but we do not recommend aspiration in our decision tree.

Muscle hernias, especially of the anterior compartment, should not be treated unless symptomatic. Conservative management with restriction of exercise and elastic support is first line and often effective 2.

Symptomatic fascial hernias are treated with generous lateral-compartment longitudinal fasciotomy. If fascial closure, either direct or by fascial graft is chosen for treatment, close postoperative surveillance is mandatory 2. Compartment syndrome can occur if side-to-side closure is performed on fascial grafts, thus requiring fasciotomy. Case studies have reported of patients with anterior compartment syndrome that require further debridement of necrotic muscle and skin grafting 6,9.

A long term consequence of anterior compartment syndrome is foot drop.

Muscle hernias of the leg usually enlarge primarily for a relative short period of time and then remain stationary. After surgery, recurrences have been reported especially when infection has occurred as a complication of operation 8.

Conclusion w/ Decision Tree Diagnosis of fascial hernias is not difficult; they are the only semi-fluctuant swellings that disappear with flexion or extension. continued on page 19

Missouri Family Physician October - December 2012 17

MAFP education gaps From the Association of Family Medicine Residency Directors

EDUCATION GAPS BETWEEN FAMILY PHYSICIANS AND LICENSED NURSE PRACTITIONERS As millions of Americans gain coverage for medical care in the coming years and as the need for primary care in patientcentered medical home (PCMH) models increases, our medical homes will need to provide more access to care. One such method is through advanced physician extenders which include physician assistants and nurse practitioners. Many entities are talking about allowing Advanced Registered Nurse Practitioners (ARNPs) work more independently without physician involvement. However, the vast difference in clinical training between family physicians and ARNPs is significant.

Also, an effective provider in a PCMH is expected to manage without consultation a broad spectrum of disease. Therefore, practices without physician counterparts could lead to a tier of primary care that is limited in its effectiveness. ARNPs are a tremendous asset in providing some primary care services, ideally partnered with physicians in group settings, but have significant limitations when independently evaluating and managing undifferentiated patients due to the superficial coverage of medical topics during their training. The skill sets are complementary to each other, but not equal.

ARNP schools exhibit a wide variation of training standards from school to school and from state to state. There is no national accreditation body like the Accreditation Counsel for Graduate Medical Education (ACGME) that monitors advanced nursing profession schools or creates national standards for clinical experiences. Without a similar structure to the ACGME, it is impossible to assess the quality of the education across these various schools.

The diagnostic challenges primary care physicians face on a daily basis require they have extensive clinical exposure in order to perform efficiently. The

depth of knowledge required to filter undifferentiated patients’ complaints and to understand the subtleties of management is vast. The average family medicine physician has 21,000 total hours of training, most of it with clear patient management responsibilities and decreasing levels of supervision. The total hours of training a nurse practitioner receives is 2,300 to 5,300 hours depending on the advanced nursing program, and much of the clinical training is observational. Many states only require a 30-day observation period of a licensed active physician before an ARNP can deliver care unsupervised. Grandfathering people into independent practice would be like grandfathering a family physician into a subspecialty after doing a month of observation in that specialty.

allow a 2nd- or 3rd-year medical student (who would have the equivalent amount of training as an ARNP), to evaluate and manage patients independently. Though states may pass laws that allow other providers with less training to practice independently, it doesn’t change the reality that without competent physician supervision, we are lowering the standard of acceptable primary care and creating a 2-tiered system of access for our community.

Todd Shaffer, MD, MBA, Michael Tuggy, MD, Stoney Abercrombie, MD, Sneha Chacko, MD, Joseph Gravel, MD, Karen Hall, MD, Grant Hoekzema, MD, Lisa Maxwell, MD, Michael Mazzone, MD and Martin Wieschhaus, MD © 2012 Annals of Family Medicine, Inc.

In the end, to practice independently, one should be judged by those who have the experience and background to make that assessment. Family physicians are the experts of primary care in this country and our understanding of what it takes to practice competently and independently is quite thorough. Family physician faculty that teach residents are skilled at making such assessments.

We believe there are excellent roles for physician extenders who work in collaborative settings with physicians, enabling more independence for the physician extenders. The medical team in the PCMH has key roles for Physician Assistants and ARNPs within its structure.

Just as physicians gain greater skill with experience, these practitioners will gain great skill in many aspects of primary care as their experience develops over time.

However, the underlying knowledge base and formative clinical experience cannot be shortcut. Not knowing what one doesn’t know can be dangerous to the public.

On the physician side, we would never

18 Missouri Family Physician October - December 2012

References 1. Ramas M–E. Texas Academy of Family Physicians (TAFP) Policy Brief. The question of independent diagnosis and prescriptive authority for advanced practice registered nurses in Texas: is the reward worth the risk? Feb 16, 2011;1–8. http://www.tafp.org/Media/ Default/Downloads/advocacy/ scope-ramas.pdf.

2. AAFP Government Relations.

Talking Points: Primary Care Workforce Distribution Data. Washington, DC: AAFP Government Relations.

3. Wulfers M. The case for cooperative health care delivery. Southeast Missourian. Feb 8, 2012. http://www.semissourian.com/ story/1813267.html?response=no.

case report MAFP Should We Remove These Lipomas? continued from page 17 Yet, clinical suspicion is often low and fascial hernias are not a part of the differential diagnosis. Similar to the case study presented above, patients with fascial hernias are often referred to the surgeon because of confusion with these lower extremity lesions with soft tissue masses. As surgical management of fascial hernias can result in serious side effects like anterior compartment syndrome, it becomes vitally important for physicians to make a correct diagnosis.

After reviewing the literature, we have constructed a diagnostic decisional tree. By using this diagnostic tool, the physician will be able to approach lower extremity lesions with a critical eye.

References 1. Alfageme, Fernando. Et Al. “Transfacial Muscular Hernia: An unusual cause

for a “hide and seek” subcutaneous nodule.” Dermatology Online Journal, Feb. 2011. Web. 09 Mar. 2012. <http:// dermatology.cdlib.org/1702/3_case_ presentations/4_11-00009/alfageme. html>.

2. Berglund HT, Stocks GW. Muscle hernia in a recreational athlete. Orthop Rev. 1993; 22(11):1246-8.

3. Egan, Thomas J., Mark Lemos, and Richard Iorio. "Muscular Herniation of the Lower Extremities." The American Journal of Orthopedics (1998): 102-06.

Print.

4. Obermayer, Maximilian E., and J. W. Wilson. "Fascial Hernia of the Legs."

JAMA(1951): 548-49. Print.

5. Lane, Joshua E., Carol M. Woody, and Jack L. Lesher. "Tibialis Anterior Muscle Herniation." American Society for Dermatologic Surgery (2002): 641-42. Print.

6. Miniaci A, Rorabeck CH. Compartment

syndrome as a complication of repair of a hernia of the tibialis anterior. J Bone Joint Surg 1968;68:1444-5 7. Siliprandi L, Martini G, Chiarelli A, Mazzoleni F. Surgical repair of an anterior tibialis muscle hernia with Mersilene mesh. Plast Reconstr Surg 1993;91:154-7.

8. Simon, Harold E., and Hugo A. Sacchet.

"Muscle Hernias of the Leg Review of Literature and Report of Twelve Cases."

The American Journal of Surgery 67.1 (1945): 87-97. Print.** 9. Wolfort, Francis G., Christian Mogelvang, and Horst S. Filtzer.

"Anterior Tibial Compartment Syndrome Following Muscle Hernia Repair." Arch Surg 106 (1973): 97-99.

Print.13

Missouri Family Physician October - December 2012 19

MAFP editorial

Awards Caps are Gone. Is Your Malpractice Insurance Ready?

by James R. Cantalin, J.D. For the past seven years, Missouri doctors have benefitted from reduced and stabilized medical malpractice insurance rates, thanks in part to the tort reform that capped non-economic damages at $350,000. However, the Missouri Supreme Court’s July 31 decision to eliminate these caps on the amount of damages sustained by an injured party will create a drastic change in the environment, and your practice needs to be ready.

Taking a walk down the memory lane of pre-2005 tort reform is not pleasant. Those were the days of skyrocketing malpractice insurance premiums, severely limited insurance carrier choices and alarming physician flight. Hundreds of Missouri physicians retired, left the state or quit their practices altogether. Premiums were simply unsustainable. Younger doctors who have entered their practices over the last several years may not even realize how challenging practicing in Missouri was at that time. The court decision ensures they will learn quickly.

In the new era, it’s important to remember that all malpractice insurance is not created equal. Understanding your policy and provider is more important than ever to protecting yourself and your practice in the event of a lawsuit.

Prior to tort reform, Missouri physicians faced dwindling choices of insurance carriers, as one after the other closed up shop in our state. However, once tort reform was enacted, there was an influx of options when insurers entered or re-entered Missouri eager for market share. Physicians were relieved to find that rates dropped as many carriers sought to undercut the competition.

But a new problem emerged: many of these providers, whose industry experience was limited to purchasing a policy, started charging actuarially unsound premiums insufficient to cover long-tail liabilities.

This is a concern because based on the history of actual claims paid, the rates these carriers charge are too low to cover the potential risk. Given that this gap was an issue even while the caps were in place, how will these carriers protect their insured physicians now that the limitation is removed and a single claim could easily run in the millions of dollars? All Missouri physicians should be aware of this issue when comparing carriers.

20 Missouri Family Physician October - December 2012

Checking a carrier’s financial viability is not difficult. All carriers are required to file an annual Statement of Actuarial Opinion with the Missouri Department of Insurance and the National Association of Insurance Commissioners. You can find the statements on the Missouri Department of Insurance website at insurance.missouri.gov in the “financial exams” section on the “companies” page.

Admittedly, these lengthy statements are challenging to review.

However, there is one key question that is telling – question six in exhibit B. It measures whether there is a significant risk that future paid amounts will be materially greater than those provided for in the reserves. In other words, is there a risk that the company will not be able to cover potential claims?

Unfortunately, in 2011 eight of Missouri’s carriers answered “yes” – indicating that these companies were at risk of being unable to cover claims. And that was before the non-economic damages caps were removed.

When you decide to compare providers, financial viability is, of course, paramount and should be a top consideration.

However, there are several additional key considerations that contribute to the overall security and value that a carrier offers, including: Market Share Ask the carrier what its Missouri market share is and what percentage of its business is conducted in Missouri. Larger market share means more insureds – this helps reduce the risk of loss by spreading out exposure.

Medical Professional Liability Insurance Experience It might seem logical that a medical liability insurance company would be managed by doctors, but in reality it’s a business that requires the expertise of seasoned insurance industry professionals who thoroughly understand the business’ long-tail liability as well as how to effectively manage premiums collected and reserves for claims known and unknown.

Client Service Outstanding client service comes from companies that are committed to serving the best interests of their insureds, not those of stockholders and/or hospitals. Also, having a main contact who is based locally in

>>

editorial MAFP

>>

Missouri is important to the quality of client service.

Reinsurance Ask the carrier if it has reinsured every policy since the company started as well as who provides the companyâ&#x20AC;&#x2122;s reinsurance. Companies that fail to secure suitable reinsurance put the solvency of the company, as well as insureds, at risk.

Advisory Boards Determine if the carrier has Missouri advisory boards.

These communications channels are important to helping a carrier stay current with healthcare industry developments as well as understanding its insuredsâ&#x20AC;&#x2122; needs.

Risk Management Credits Good carriers reward physicians with premium credits for participating in risk management programs that offer many ways for physicians to enhance the safety and quality of care and reduce errors.

Claims Management Swift claims management is vital to effective practice management. Ask the carrier what percentage of all claims filed in the last five to 10 years have been closed and how long, on average, it takes the company to close a claim in Missouri.

Omission - Match Results In the Jul-Sep 2012 issue of the Missouri Family Physician magazine, the Mercy Family Medine Residency was inadvertantly omitted from the Resident Report in terms of the Match 2012 results (page 7).

The program had 6 residents, 1 each from SLU, MU, UMKC, 2 from ATSUKirksville and 1 from Oceana University.

We sincerely apologize for the oversight.

Rates Rate swings are not inevitable. Well-run carriers develop strategies to stabilize rates. Ask the carrier how many times it has raised rates in the last 10 years.

Evaluating your medical malpractice insurance is likely something you do periodically as part of responsible practice management, but tort reform overturn provides a significant impetus to conduct this evaluation immediately.

While the cycle of tort reform damage caps is typically cyclical, historically it has taken years to resolve â&#x20AC;&#x201C; meaning we should not look for caps to return anytime in the near future. In the meantime, you need to know if your insurer is prepared to deal with the new risk environment, and if getting prepared equates to a rate increase for you.

James R. Cantalin, J.D. is the General Counsel for Missouri Professionals Mutual, the largest professional liability provider in Missouri in both market share and membership since 2004.

Cantalin is a member of the Missouri Bar, Lawyers Association of St. Louis, Missouri Organization of Defense Lawyers and Missouri Society of Health Care Attorneys.

Missouri Family Physician October - December 2012 21

MAFP cox family medicine

22 Missouri Family Physician October - December 2012

mercy family medicine MAFP

Missouri Family Physician October - December 2012 23

MAFP university of missouri family medicine

24 Missouri Family Physician October - December 2012

saint louis university family medicine MAFP

Attention Residents!

Do you need to be published?

Are you interested in submitting your report to be published as a Resident Grand Rounds article in our quarterly Missouri Family Physician magazine? Contact MAFP Staff at (573) 635-0848 for more information.

Missouri Family Physician October - December 2012 25

MAFP Research family medicine

26 Missouri Family Physician October - December 2012

umkc family medicine MAFP

Missouri Family Physician October - December 2012 27