Mfp magazine jan mar 2012 for web by Missouri Academy of Family Physicians

MISSOURI

Official Publication of the Missouri Academy of Family Physicians

Family Physician

JAN â&#x2C6;&#x2019; MAR 2012 Volume 31, Issue 1

Katie Dias, DO MAHEC Partnership Helps Produce Homegrown Physicians pg. 12

Resident Grandrounds

Smart Phone Apps: The New

Charles Coyne, III, MD pg. 14

Trend in Medicine pg. 6

Go Paperless and Get Paid Register NOW for CMS Electronic Health Record Incentives

The Centers for Medicare & Medicaid Services (CMS) is giving incentive payments to eligible professionals, hospitals, and critical access hospitals that demonstrate meaningful use of certified electronic health record (EHR) technology. Incentive payments will include: • Up to $44,000 for eligible professionals in the Medicare EHR Incentive Program • Up to $63,750 for eligible professionals in the Medicaid EHR Incentive Program • A base payment of $2 million for eligible hospitals and critical access hospitals, depending on certain factors Get started early! To maximize your Medicare EHR incentive payment you need to begin participating in 2011 or 2012; Medicaid EHR incentive payments are also highest in the first year of participation. Registration for the EHR Incentive Programs is open now, so register TODAY to receive your maximum incentive. For more information and to register, visit: www.cms.gov/EHRIncentivePrograms/ For additional resources and support in adopting certified EHR technology, visit the Office of the National Coordinator for Health Information Technology (ONC): www.HealthIT.gov

contents MAFP

Executive Commission Board Chair Keith Ratcliff, MD (Washington) President Todd Shaffer, MD, MBA (Leeâ&#x20AC;&#x2122;s Summit) President-elect Kate Lichtenberg, DO, MPH (Kirkwood) Vice President Bill Fish, MD (Liberty) Secretary/Treasurer David Kapp, MD (Perryville) Board of Directors District 1 Director: Dana Granburg, MD Alternate: Jennifer Moretina, MD District 2 Director: Gemma Ciesemier, DO Alternate: Vacant District 3 Director: Jeff Suzewits, DO Director: F. David Schneider, MD Alternate: Vacant District 4 Director: Kelly Bain, MD Alternate: Jennifer Stearnes-Rosas, MD District 5 Director: Peter Koopman, MD Director: Katherine Friedebach, MD Alternate: James Stevermer, MD, MSPH District 6 Director: Jamie Ulbrich, MD Alternate: Vacant District 7 Director: Daniel Purdom, MD Director: Kathleen Eubanks-Meng, DO Alternate: George Harris, MD, MS District 8 Director: Mark Woods, MD Director: Tracy Godfrey, MD Alternate: Paul Stortz, MD District 9 Director: John Paulson, DO, PhD Alternate: Vacant District 10 Director: Mark Schabbing, MD Alternate: Steven Douglas, MD At-large Director: Robert Schneider, DO Resident Directors Mimi Moon-Propst, MD Suzan Lewis, DO (Alternate) Student Directors Aaron Meyer David Kramer (Alternate) AAFP Delegates Bruce Preston, MD Larry Rues, MD Dave Campbell, MD (Alternate)

Mark Your

Calendars 2nd Annual Advocacy Day, State Capitol, Jefferson City, MO February 28, 2012 AAFP NCSC, Kansas City, MO May 3-5, 2012 64th Annual Scientific Assembly, Resort at Port Arrowhead, Lake Ozark, MO June 22 - 24, 2012 20th Annual Fall Conference & SAM Working Group, Big Cedar Lodge, Ridgedale, MO November 9-11, 2012

2012 Annual Scientific Assembly

Inside this issue 18 Thank You 2011 AFC Sponsors & Exhibitors

Member Services

Gen Y Family Physicians

Smart Phone Apps: The New 20 Trend in Medicine 26 ProAssurance Bulletin Help Desk Answers 27

Kate Lichtenberg, DO, MPH Todd Shaffer, MD, MBA, FAAFP

Resident Case Studies

19 2012 Annual Scientific Assembly Coming in June Residency Programs Family Physician of the Year Call for Nominations 2012 Advocacy Day Registration

Advertisements

Members in the News

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

Districts at a Glance

MAHEC Partnership Helps Produce Homegrown Physicians Jennifer Bauer, Executive Director

16 HEALTHeCAREERS

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

Help Desk Answers

17 United Allergy Labs

Resident Grandrounds

p (573) 635-0830 f (573) 635-0148 www.mo-afp.org office@mo-afp.org

Resident Case Studies Charles Coyne, III, MD

2 CMS 7 SSM Medical Group 11 PedsPal

18 Bristol Manor 19 TransforMED 28 Missouri Professionals Mutual January - March 2012

Missouri Family Physician

MAFP member services

Are You Prepared for 2012? Kate Lichtenberg, DO, MPH MAFP President-Elect/MAFP Member Services Commission Co-Chair

his is the time of year when we see a lot of “Year in Review” lists. The tornadoes that hit around the state starting in St. Louis County on New Year’s Eve 2010, the Good Friday tornadoes, and the Joplin tornado in May topped many lists in Missouri. The Joplin tornado topped many national lists as well. Do you know what you and your practice would do in the event of a tornado or other disaster? The events of the past year have made me stop to think about how I would get my practice up and running again (and thanks to Tracy Godfrey, MD, for sharing her story in the Jul-Sep 2011 issue of the Missouri Family Physician) but I also realized I need to think about my family and the day-to-day things that could have an impact there.

I was fortunate to represent the MAFP membership at a two-day planning event in Jefferson City sponsored by the Department of Health and Senior Services (DHSS) where we did just that. The overarching message from many who were involved in Joplin and other disasters around the state was to remember your selfcare and your family’s care. Since we are already so busy with our everyday activities, spending time planning and preparing for something that may never happen is likely not high on many people’s to-do lists. It doesn’t take a lot of time to at least prepare at home. DHSS Center for Emergency Response and Terrorism offers some great resources. I encourage you to check them out. The AAFP also offers resources on their website www.aafp.org.

Also, please mark February 28, 2012, on your calendars now. We will be hosting our second annual Advocacy Day at the State Capitol in Jefferson City. Please consider taking one day to come and meet with your legislators and talk with them about the challenges you face whether you are in solo practice, academics, work in a group setting, urban, or rural. They really are interested in the challenges you face taking care of their constituents. You don’t know what to talk to them about? There will be a briefing ahead of time to get you up to speed on issues your Academy is working on. Please contact the MAFP office at (573) 635-0830 for more information or see page 29 in this publication for a registration form. As always, we want to hear from you. May your 2012 be happy, healthy, and safe!

Today more than 3,500 children will try their first cigarette.

Stop kids from starting. Volunteer to be a Tar Wars presenter. www.tarwars.org

Missouri Family Physician January - March 2012

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

gen y family physicians MAFP

Gen Y Family Physicians and "The Canary in the Mine" Todd Shaffer, MD, MBA, FAAFP MAFP President

hings are changing in Family Medicine. My primary job away from taking care of patients and as President of the Missouri Academy is as program director of one of the largest family medicine (FM) residency programs in the country. As you may remember from residency days, we are well into the interview process for choosing the class of 2015 for our programs across the country. I want to take the opportunity to describe the characteristics of this next group of some of the bravest and most altruistic group of applicants I have come across in the past 20 years. During my last decade as program director, I have seen what I describe as the “Dark Ages” of Family Medicine (2000 to 2008). During this time, there was a great loss of focus of all the positive reasons most of us entered into family medicine. There were a lot of naysayers in our own ranks of FM physicians, academic faculty, student interest, and specialists in academics. There were many things I read and listened to during this time by students and docs alike about how family medicine and primary care was dying. We saw specialists’ salaries skyrocketing due to reimbursement strategies of the RUC and other payers, while family medicine was flat. I intensely studied this trend during my Physician Leadership MBA program at Rockhurst from 2004 to 2007. The more I read, the harder it was to find positive things about family medicine. Students were being told that they were too smart to go into family medicine. Students were saying no one is smart enough to go into family medicine because there is too much to learn and it is too broad spectrum. During this time in Missouri, there were three FM programs closed with the loss of over 20 graduates per year. Nationally there

were over 25 FM programs that closed during that same time with the loss of over 600 positions through other programs downsizing. As FM programs downsized and DME cap slots were gobbled up by specialty fellowships and subspecialties of Internal Medicine (IM), the numbers of general practice IM docs graduating nationally dropped to now less than 5% of those that complete IM residencies. Our healthcare system has continued to become further fragmented, expensive, and outcomes have not been improving over the last 20 years. Compare this to some 30 other country healthcare systems where we still rank below healthcare outcomes that are all primary care based. In studying economics of healthcare and business, I could not understand why the free market system was not working. Why was it that FM docs’ incomes were stagnant and specialists’ salaries were increasing at 2-3 times the rate of inflation, along with the price of healthcare as a proportion of U.S. GDP going from 11% to 18% during these years? Family Medicine is the most recruited specialty by all the large national firms since 2004. In a perfect economic system, supply and demand rules. If family medicine is so needed, why was that not working? There must be other forces at work. I might blame the RUC, insurance companies and large hospital systems who armed themselves to capitalize on high dollar proceduralists, machines, and technology. Primary care was quietly providing lower costs and higher quality and keeping people out of those high cost procedures and hospitalizations. It is difficult to measure the amount of expenditures we prevent in primary care. Big industries like IBM, and the writings of people like the late Barbara Starfield, took notice

of the advantages of primary care. What we know to be our value is recognized by the largest payer for medical services in the U.S. - the federal government. The Affordable Healthcare Act provided the emphasis back on the patient-doctor relationship. Patient Centered Medical Home (PCMH) is mentioned over 125 times in the Affordable Healthcare Act. Businesses are re-evaluating the types of quality they get from the U.S. healthcare system for its cost as the most expensive in the world. Some have now figured out you cannot commoditize primary care the way you might some service line like cataract surgery. Family Medicine is about relationships. Every high performing national healthcare system in the world is based on primary care where more than half their physicians are primary care doctors. Yet in the U.S., less than 25% (and dwindling) of the physicians are providing primary care. We are going in the wrong direction for where we need to go; the free market system does not bear out. Most sources now estimate we will be short by 40,000 family physicians by 2020 in the U.S. and about 700 short in Missouri. The baby boomer generation is retiring and seeking more healthcare. After 40-year careers, some of our first graduates of FM residencies are now retiring, adding to the shortage. Things are changing though ... like the original Dark Ages, afterwards came the Renaissance. Since 2009, we are seeing positive signs of entering the family medicine renaissance. We have reached the bottom of the trend on student interest on family medicine. Numbers have been up the last two years. Payers, including employers, are looking how they can get the continued on page 7 January - March 2012

Missouri Family Physician

MAFP proassurance bulletin

Smartphone Apps: The New Trend in Medicine A smartphone isn’t just a phone. It’s a miniature computer. We surf the web, email, play games, and—thanks to the rapidly expanding world of smartphone applications (“apps”)–use our smartphones and other wireless devices as tools for the workplace. The field of medicine is changing rapidly with the growth of available medical apps. Today, physicians can monitor a patient’s vital signs, download their patient schedules, access current patient medical records, dictate office notes, and consult with other physicians without entering a clinical setting. One of the first medical apps in use—and arguably the most widely used medical app today—is Epocrates,1 which provides clinical information on thousands of prescription and over-the-counter drugs.2 Another useful tool, Mediquations, is a medical calculator that includes 229 medical formulas and scoring tools.3 Examples of apps available to specialty fields include the ACC Pocket Guidelines for cardiology, Anesthesiology i-pocketcards, and CORE— Clinical Orthopedic Exam for orthopedic surgeons. Such apps provide a multitude of up-to-date references immediately accessible at the time of care. Unlike reference apps, AirStrip OB is a semi-interactive app that is taking the obstetrical world by storm. AirStrip OB allows physicians to monitor fetal heart tracings and maternal contractions in real time on their mobile devices.4 AirStrip Technologies has created additional apps to include more areas of inpatient and home care management. While patients may be comforted knowing their physician can remotely monitor what is occurring, such apps should not take the place of face-toface interaction. Another recent trend includes mobile dictation, which allows physicians to dictate information that can be transmitted and/or directly transferred to an electronic health record. In some cases, these apps also allow physicians to view patient lists, search patient IDs, and display current patient information on their mobile device.5 6

Missouri Family Physician January - March 2012

New Technology—New Risks As with any new medical device, there are risks. Unsecured smartphones can be “plundered by cybercriminals for data,” and smartphone apps are “often overlooked when it comes to testing the security of smartphones.”6 The Health Information Technology for Economic and Clinical Health (HITECH) Act requires notification whenever a breach of unsecured protected health information (PHI) occurs.7 Additionally, the Department of Health and Human Services requires security of PHI on storage devices (hard drives), transmission media (cyberspace), and portable electronic media (e.g., smartphones).8 Consider the types of information stored on your mobile device. Reference guides such as Epocrates should not be a HIPAA risk. However, PHI saved directly to the device by dictation apps should be secure. Beyond storage issues, physicians should consider the security of PHI transmitted via mobile devices. Apps such as Airstrip OB that transmit PHI could be intercepted by hackers and/or corrupted by a virus. This risk can be mitigated by using encryption software that makes the data unusable by any party who may intercept it during transmission. Some app creators, like AirStrip Technologies, advertise their products as HIPAA compliant.9 Regardless of whether a physician’s mobile device is used to access, transmit, or store PHI, consider all HIPAA and HITECH requirements. HIPAA requires data security and proper destruction, and/ or file retention of PHI when appropriate. Before discarding devices with apps, physicians should have PHI removed to ensure HIPAA compliance. What Can You Do? • Review potential wireless apps to ensure security of PHI at all levels; • Limit the type of apps that can be used based upon the individual app’s level of security; • Develop a security policy addressing mobile devices and apps that can be used, along with the appropriate use and destruction of PHI data;

• Develop an eDiscovery policy requiring assistance from defense counsel or your local ProAssurance risk management office in retaining PHI in the event of litigation; and • Work closely with IT personnel to address all security issues. References 1, 2, 3 Neal, H. “The Best Medical iPhone Apps for Doctors and Med Students.” Software Advice Blog, December 9, 2010, www. softwareadvice.com/articles/medical/thebest-medical-iphone-apps-for-doctors-and-medstudents-1100709/#ixzz1B34Cg6c4 (accessed January 11, 2011). 4, 9 Farrel, J. “Marketing Deal to Extend AirStrip OB Reach.” The Mobility Blog, August 31, 2010, www.mobilehealthwatch.com/blog/ marketing-deal-extend-airstrip-ob-reach (accessed December 17, 2010). 5 Dolan, B. “3M Launches Smartphone Physician Dictation App.” December 16, 2009, www. mobilehealthnews.com/5793/3m-launchessmartphone-physician-dictation-service/ (accessed January 12, 2011). 6 Wysopal, C. “Smartphone App Security Issues Being Overlooked by Companies.” July 21, 2010, http://www.infosecurity-us.com/view/11133/ smartphone-app-security-issues-being-overlookedby-companies (accessed December 17, 2010). 7, 8 Guidance Specifying the Technologies and Methodologies That Render Protected Health Information Unusable, Unreadable, or Indecipherable to Unauthorized Individuals for Purposes of the Breach Notification Requirements Under Section 13402 of Title XIII of the American Recovery and Reinvestment Act of 2009; Request for Information, 74 Fed. Reg. 19,006 (2009). Author: Jenice M. Deming, JD, Risk Management Consultant. Copyright © 2011 ProAssurance Corporation.

This article is not intended to provide legal advice, and no attempt is made to suggest more or less appropriate medical conduct.

gen y family physicians MAFP Gen Y Family Physicians continued from page 5

best quality at a fair price. Family Medicine programs are expanding, there are several new programs starting across the country (new residency at Saint Louis University last year) and only one FM program has closed in the nation in the past two years. As Iam presently serving as Treasurer of the Association of Family Medicine Residency Directors (AFMRD), many organizations are contacting our organization to find out how to start up FM programs. The federal government has been putting money into expanding primary care programs. UMKC was able to expand our primary care programs by four per year (two in FM and two in general IM) out of the 82 slots, and the only expansion was for government sponsored slots. Financial incentive payments to primary care physicians are now becoming reality. This all sounds great, but what about our most valuable resource? What about Gen Y student interest? As a program director, I feel as though I am the “Canary in the Mine” and we are getting ready for an explosion. As I read their personal statements for their reasons to enter family medicine, the messages have greatly changed from what I read just a couple of years ago. Generational researchers tell us that Gen Y is more likely to volunteer than previous generations. This generation loves change, communication, and challenging the status quo (think 60’s and the founders of Family Medicine). They are connected and like to connect in a world they have never known without computers. They really believe they can make a difference. They challenge authority and are more in tune as servant leaders. This demonstrates to me that practicing FM docs have come around in their view of their specialty as well. Although many were very pessimistic over the last decade, the number one reason students tell me they chose Family Medicine this year is because of their rotation with a FM preceptor and how they view a FM doctor as a “real doctor” who values patient relationships and who can help their patients in ways like no other specialty.

This year our FM program has 50% more applicants, we have invited 30% more to interview than ever before, and will be interviewing 25% more than we ever have with students on a waiting list to interview. They are bright-eyed, smart, tech savvy, excellent communicators and already FM advocacy experienced. These are the best and brightest I have ever seen in my 20 years. What a great time for Family Medicine! But the true measure of knowing we are ready for an upswing is when I read one applicant’s personal statement. Her father was a family doctor who died when she was 14. She had considered other specialties strongly through medical school, but decided that Family Medicine, like her father chose, is defined as a true calling and being what she called a real doctor. She is among the strongest residency candidates you would ever meet. Along with her, I

have five other candidates who have family doctors as parents. We currently have two of our residents with family physician parents. That is truly a measure of success with the next generation of family doctors. I am excited about Family Medicine as we are recognized as caring, empathetic physicians training in the PCMH model for the next generation. We will meet the challenge, and as my Chair always points out, if you take care of people, service, and quality - the finances and growth will follow. So get ready for the Gen Y’ers ... because they are now here and they will have expectations for practicing in a PCMH environment. I have confidence that I, personally, will be well taken care of by this next generation. Thank you for honoring me to represent all 1,700 members of the MAFP

January - March 2012

Missouri Family Physician

MAFP help desk answers About HDAs - Resident authors work directly with a physician faculty mentor as “author teams”. Residencies meet RRC requirements, and many programs have developed their faculty into local evidence-based medicine experts!

What is the best initial management for acute symptomatic hyperphosphatemia? Evidence-Based Answer Emergent hemodialysis is the treatment of choice in acute life-threatening symptomatic hyperphosphatemia. (SOR: C, based on a consensus guideline recommendation and case reports.) For asymptomatic hyperphosphatemia, initial treatment is phosphate restriction in intravenous solutions, intravenous fluid administration, and administration of phosphate binders. (SOR: C, expert opinion.) Acute hyperphosphatemia, occurring in the absence of chronic kidney disease, is typically seen in tumor lysis syndrome, rhabdomyolysis, hemolysis, chronic use of phosphate-containing antacids, or administration of phosphate-containing enemas.1 A case study from 1980 presented a 15-monthold boy with excessive iron ingestion who accidently received 60 mL of a concentrated solution of 66% sodium phosphate. The patient became obtunded, hypotensive, tachypneic, and febrile. His QT interval was prolonged to 0.5 seconds. The patient’s hyperphosphatemia (24.6 mg/dL) was treated with intravenous 10% dextrose in 75 mmol/L NaCl with 30 meq/L KCl at 250 mL/kg per day, in addition to a one-time dose of intravenous calcium gluconate 1.7 g over 5 minutes. The patient showed clinical improvement in 4 hours and a return to normal phosphate levels at 18 hours.2 A 1994 case study presented a 4-year-old boy who developed tumor lysis syndrome after chemotherapy for acute lymphoblastic leukemia. Forty-eight hours after initiation of chemotherapy, the patient developed oliguric acute renal failure (creatinine 1.3 mg/ dL) and acute symptomatic hyperphosphatemia (19.1 mg/dL). He was treated with hemodialysis and his serum phosphate was reduced to 6.7 mg/dL. However, 4 hours later, he had recurrent hyperphosphatemia (19.3 mg/dL) and was subsequently, and successfully, treated with a combination of hemodialysis followed by continuous veno-venous hemofiltration for a total of 52 hours. The treatment was stopped once his phosphate and renal function returned to normal.3 A case study in 2005 presented a 37-year-old man who developed tumor lysis syndrome after chemotherapy for nonHodgkin’s lymphoma. Three days after chemotherapy, he complained of fatigue, difficulty breathing, and decreased urinary 8

Missouri Family Physician January - March 2012

September 2011 EBP

output. He was initially treated with infusions of normal saline and high doses of diuretics without any effect on his urine output. On day 4, he developed hyperphosphatemia (18.9 mg/ dL) and worsening acute renal failure (creatinine 3.6 mg/dL). The patient was then treated with 4 rounds of daily hemodialysis. Hemodialysis was stopped when his phosphorus normalized and his urinary output was more than 1,500 mL/d.4 In 2008, guidelines on management of tumor lysis syndrome were published by a panel of experts in pediatric and adult hematologic malignancies. For asymptomatic hyperphosphatemia, recommended initial treatment is phosphate restriction in intravenous solutions, intravenous fluid administration, and administration of phosphate binders. Hemodialysis, continuous veno-venous hemofiltration, or peritoneal dialysis is recommended for the treatment of symptomatic hyperphosphatemia. The guideline authors acknowledged that the recommendations were based on evidence from case reports.5 Cesar Espiritu, MD Corey Lyon, DO Research FMR Kansas City, MO 1. Shiber JR, Mattu A. Serum phosphate abnormalities in the emergency department. J Emerg Med. 2002; 23(4):395–400. [LOE 5] 2. Geffner ME, Opas LM. Phosphate poisoning complicating treatment of iron ingestion. Am J Dis Child. 1980; 134(5):509–510. [LOE 4] 3. Sakarcan A, Quigley R. Hyperphosphatemia in tumor lysis syndrome: the role of hemodialysis and continuous venovenous hemofiltration. Pediatr Nephrol. 1994; 8(3):351–353. [LOE 4] 4. Karagiannis A, Tsorlalis I, Kakafika A, Pateinakis P, Perifanis V, Harsoulis F. Acute renal failure due to tumor lysis syndrome in a patient with non-Hodgkin’s lymphoma. Ann Hematol. 2005; 84(5):343–346. [LOE 4] 5. Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol. 2008; 26(16):2767–2778. [LOE 2a]

help desk answers MAFP

Are topical heat wraps effective for acute low-back pain? December 2011 EBP

Evidence-Based Answer Yes, topical heat wraps are effective treatment of acute and subacute low-back pain. (SOR: A, based on a systematic review and RCTs with consistent findings.) A Cochrane review of 9 RCTs and nonrandomized controlled clinical trials examined superficial heat or cold therapies for lowback pain, compared with placebo, no therapy, or other therapies.1 Participants were 18 years or older with nonspecific low-back pain. The primary outcomes measured were pain and physical functional status. In 2 of the trials, in which 258 patients had a mix of acute (<6 weeks) and subacute (6–12 weeks) low-back pain, heat wrap therapy significantly reduced pain after 5 days (weighted mean difference (WMD) 1.06; 95% CI, 0.68–1.45; scale range, 0–5) compared with oral placebo. One trial of 90 participants with acute lowback pain found that a heated blanket compared with a nonheated blanket significantly decreased acute lowback pain 25 minutes after application (WMD –32.20; 95% CI, –38.69 to –25.71; scale range, 0–100).1 The trials included were of varying methodological quality, with 5 of the 9 trials being rated as high quality (based on a risk of bias assessment) and 4 as low quality. Evidence was insufficient to evaluate the effects of cold for acute low-back pain.1 In a 2006 RCT of 32 healthy adults without back pain (asymptomatic), heat wrap therapy (n=16) was compared with cold pack therapy (n=16) after patients performed an exercise protocol designed to induce delayed-onset muscle soreness of the low back.2 At 18 hours postexercise, participants applied either a heat wrap or a cold pack. The heat wrap was applied 2 times for 8 hours each beginning at hours 18 and 32 postexercise. The cold pack was applied for 15 to 20 minutes every 4 hours between 18 and 42 hours postexercise. Using a 6-point pain relief score, at 24 hours postexercise the mean pain relief score for the heat wrap group was significantly greater than for the cold pack group (1.5 vs 0.6, respectively; P=.026). This study was supported by Procter & Gamble, a manufacturer of heat wraps.2 A 2005 RCT compared heat wrap therapy plus education with education only in 43 adult patients (ages 20–62) who presented

to an occupational injury clinic with an acute episode of low-back pain.3 Eighteen patients were assigned to the education-only group (written handout on recognition and treatment of low-back pain) and 25 patients were assigned to the ThermaCare Heat Wrap group (applied daily for 3 consecutive days, removed at the end of the day) combined with the educational handout. Pain intensity was measured on a 0 to 10 categorical scale and pain relief was measured on a 0 to 5 scale (0=no relief, 5=complete relief). Patients completed both scales 4 times daily for 14 days. Compared with the education-only group, the heat wrap group had significantly lower pain intensity during the 3-day treatment period (weighted mean difference [WMD] –2.05 on day 3; 95% CI, –3.34 to –0.76). Better scores persisted to the last day of follow-up (WMD –1.63 on day 14; 95% CI, –2.92 to –0.34). Pain relief was also significantly better in the heat wrap group during therapy (WMD 1.53 at day 3; 95% CI, 0.76 to 2.3) and persisted through the end of the study (WMD 1.21 on day 14; 95% CI, 0.26 to 2.14).3 Jennifer Kelley, MD Kavitha Arabindoo, MD Gazala Parvin, MD Sandy Lepinski, MD Shari Ommen, MD Research FMR Kansas City, MO 1. French SD, et al. Cochrane Database Syst Rev. 2006; (1):CD004750. [LOE 1a] 2. Mayer JM, et al. Arch Phys Med Rehabil. 2006; 87(10):1310– 1317. [LOE 1b] 3. Tao XG, et al. J Occup Environ Med. 2005; 47(12):1298–306. [LOE 1b]

January - March 2012

Missouri Family Physician

MAFP MEMBERs in the news

Members in the news

Michael LeFevre, MD

Fred Rottnek, MD

MU School of Medicine graduate and faculty member Michael LeFevre, MD, has been elected to the Institute of Medicine of the National Academies, one of the highest honors in the fields of health and medicine. LeFevre, vice chair of family and community medicine, is widely recognized as a leading scholar, clinician, educator, policy expert and champion for electronic health records. On November 19, 2011, Fred Rottnek, MD, was presented with the Annual Greater St. Louis Community Health Award at the SLAFP Annual Installation Banquet of Officers and Board of Directors. Dr. Rottnek received the award for years of serving the juvenile and adult

Dana Granberg, MD

Jennifer Moretina, MD

prisoners of St. Louis County, volunteer physician with the St. Louis Area Effort for AIDS, and direction provided SLU 1st and 2nd year students to incorporate community service and outreach activities as part of their education. Currently, Dr. Rottnek serves as instructor and advisor to Saint Louis University students seeking community outreach options. He serves as Medical Director for Area Health Educators Consortium. The Missouri Academy of Family Physicians would like to introduce its newest additions to the Board Roster. Representing District 1 is Director Dana Granberg, MD (Kansas City) and Alternate Director Jennifer Moretina, MD (Liberty).

Jamie Ulbrich, MD

John Paulson, DO, PhD

Representing District 6 is Director Jamie Ulbrich, MD (Marshall) and there is a vacancy in the Alternate Director Position. Representing District 9 is Director John Paulson, DO, PhD (Licking) and there is a vacancy in the Alternate Director Position. There is also a vacancy in the Alternate Director position in District 2 and District 3. Representing District 10 is Alternate Director Steven Douglas, MD (East Prairie) (not pictured). (If you are interested in a leadership position or serving on a Commission, please contact MAFP staff at (573) 635-0830 or complete a volunteer form found on MAFP’s website www.mo-afp.org. For the Board vacancies, you must reside or work in the county you represent.

Districts at a glance According the MAFP's By-Laws, the Board of Directors shall be composed of the chair, the two AAFP delegates, up to four at-large directors appointed by the Executive Commission, one resident director, one student director and directors from ten (10) Districts. Each of the Districts, shall be represented by one (1) director, except districts 3 and 7 shall be represented by two (2) directors. The resident and student directors, and two (2) AAFP delegates of the Board of Directors have full voting privileges. For all purposes 10 Missouri Family Physician January - March 2012

of the MAFP Bylaws, and this Chapter VIII, the ten (10) Districts, shall be as follows: District 1 – Atchison, Nodaway, Worth, Harrison, Mercer, Holt, Andrew, Gentry, Daviess, Grundy, Linn, Buchanan, DeKalb, Caldwell, Livingston, Carroll, Platte, Clinton, Clay District 2 – Putnam, Schuyler, Scotland, Clark, Sullivan, Adair, Knox, Lewis, Macon, Shelby, Marion, Chariton,

Randolph, Monroe, Ralls, Pike District 3 – City of St. Louis, St. Louis County, St. Charles District 4 – Lincoln, Warren, Gasconade, Franklin District 5 – Howard, Boone, Audrain, Cooper, Callaway, Montgomery, Morgan, Moniteau, Cole, Osage, Camden, Miller

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District 6 – Ray, Lafayette, Saline, Cass, Johnson, Pettis, Bates, Henry, Benton, Vernon, St. Clair, Hickory, Cedar District 7 – Jackson District 8 – Barton, Dade, Polk, Dallas, Laclede, Jasper, Lawrence, Greene, Webster, Wright, Newton, Christian, McDonald, Barry, Stone, Taney District 9 – Maries, Pulaski, Phelps, Crawford, Dent, Texas, Shannon, Howell, Douglas, Ozark, Oregon District 10 – Jefferson, Washington, Ste. Genevieve, St. Francois, Iron, Reynolds, Carter, Ripley, Butler, Wayne, Madison, Perry, Bollinger, Cape Girardeau, Scott, Stoddard, New Madrid, Mississippi, Dunklin, Pemiscot There shall be elected an alternate director from each of the ten (10) Districts, two (2) alternate AAFP delegates, an alternate resident director, and an alternate student director.

The map above outlines the ten districts according to MAFP By-Laws January - March 2012

Missouri Family Physician

MAFP member spotlight

MAHEC Partnership Helps Produce Homegrown Physicians

by Jennifer Bauer, MAFP Executive Director

n the previous issue of the Missouri Family Physician magazine, MAFP Board Chair Keith Ratcliff, MD, explained how MAFP is exploring a partnership with Missouri Area Health Education Centers (MAHEC) and ways in which active physicians can get involved by professional shadowing. As MAFP continues to explore this partnership with MAHEC, three “new” physicians came to mind who completed their journey along the pipeline. Molly Harp, DO, of Cameron, always knew she wanted to be a doctor. As she talked about E.R. Schmidt, DO, who is a former mentor. She described Dr. Schmidt as the typical small town doctor who was very involved in his community. She explained how she was fortunate to shadow him, and he even “white-coated” her during her first year of medical school. Dr. Harp indicated that Dr. Schmidt didn’t always paint a rosy picture of the primary care physician, but that didn’t discourage her from following her dream. Dr. Harp’s first experience with AHEC was her participation in the college

preparatory academy at Truman State University in Kirksville. It was a four-week, college-like experience with courses such as biology, physics, and chemistry. The academy enhanced her desire to continue her goal to someday become a physician and knew her place was to be in a small town -- it was like a “calling.” Katie Dias, DO, of Albany, credits the combination of AHEC resources and Primary Care Resource Initiative for Missouri Photo by Jacob Fenston/KBIA (PRIMO) funding, along with the staff at her hometown hospital, for helping guide her interest into the medical field. She specifically mentioned Angela Martin, MD, the late Michael Coleman, DO, and Arturo Tenorio, MD. Dr. Dias says she feels a commitment to the community who raised her, and she encourages other physicians to open up their offices to students. If we all (physicians) participate, “we can help bridge that gap.” The gap Dr. Dias is referring to is the primary care workforce crisis. Laura Harbison, DO, also practices in Cameron and her involvement in AHEC and PRIMO did not occur until

As a third-year medical student, Katie Dias, DO, is pictured above helping at an AHEC workshop involving middle school students. 12 Missouri Family Physician January - March 2012

her sophomore year in college. She recalled her attendance at the workshops in Kirksville during the summer. She also shadowed James Neely, DO, during the summer months. Her first glimpse at a possible career in the medical field was when she worked at the local hospital back in high school performing administrative jobs and filing. She is thankful for the SWMO AHEC for their assistance in helping her secure rotations. She also participated in the AHEC’s legislative days. Dr. Harbison said that she is very happy with her decision to come back home. All three physicians share a common bond of extreme enthusiasm for their profession and their patients. It was a pleasure speaking with each of them as they described their journey. MAFP commends the physicians involved in influencing students to become interested in primary care. Hopefully these stories inspire additional physicians to get involved in this process. It is refreshing that retaining talent in Missouri can be achieved as MAFP continues to utilize this “homegrown” approach.

Above: Katie Dias, DO, is assisting students at a AHEC Pipeline workshop held in December at Northwest Medical Center in Albany.

help desk answers MAFP 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! January 2012 EBP

What antibody studies are helpful in the diagnosis of Hashimoto's thyroiditis? Evidence-Based Answer While anti-thyroid peroxidase (anti-TPO) antibodies and anti-thyroglobulin (anti-Tg) antibodies both have high specificity (>90%) for the diagnosis of Hashimoto’s thyroiditis, anti-TPO antibodies are a more sensitive. Routine antibody testing, however, is not generally recommended in the setting of uncomplicated hypothyroidism. (SOR: C, based on expert opinion.) A case series included 150 patients with a definitive tissue diagnosis of Hashimoto’s thyroiditis by fine-needle aspiration cytology. Using an enzyme-linked immunosorbent assay, 79% of patients were anti-TPO positive and 67% of patients were anti-Tg positive. One or both antibodies were positive in 89% of patients; only 11% of patients were negative for both antibodies.1 No data were provided on biopsy-negative patients, preventing calculation of sensitivity or specificity. A case-control study compared 111 patients with clinically diagnosed Hashimoto’s thyroiditis and 414 controls (including 120 healthy patients and 294 patients with infectious or autoimmune diseases). The sensitivity and specificity of anti-TPO were 92% and 93%, respectively (calculated LR+ 13, LR– 0.09). The sensitivity and specificity of anti-Tg were 73% and 92% (LR+ 9.7, LR– 0.29). Approximately 68% of patients with Hashimoto’s thyroiditis were positive for both antibodies, whereas only 1.8% were negative for both antibodies.2 Including patients with autoimmune disease as controls could potentially have increased false-positive antibody results and decreased specificity. An additional case-control study compared 93 patients with clinically diagnosed Hashimoto’s thyroiditis who presented at a regional hospital over a 4-year period with 292 healthy controls. Eighty-eight patients with Hashimoto’s thyroiditis were anti-TPO positive compared with only 3 controls (sensitivity 95% and specificity 99%; LR+ 92, LR– 0.05). Also, 71 patients with Hashimoto’s thyroiditis were anti-Tg positive compared with only 3 controls (sensitivity 76% and specificity 99%; LR+ 74, LR– 0.24).3 The American Association of Clinical Endocrinologists (AACE) Thyroid Task Force

guidelines make no specific recommendation regarding laboratory testing of thyroid antibodies in the setting of clinical hypothyroidism. However, the guidelines do suggest that anti-TPO and anti-Tg tests can be used to confirm the diagnosis of Hashimoto’s thyroiditis. Consistent with the reviewed studies, the AACE consensus paper reported that autoantibodies are positive in 95% of patients with Hashimoto’s thyroiditis and that high titers are of considerable value in diagnosing Hashimoto’s thyroiditis (no evidencebased citation).4 Nathan Granneman, MD Laura Morris, MD University of Missouri Columbia, MO 1. Singh N, et al. Acta Cytol. 2009; 53(5):507-516. [LOE 2b 2. Tozzoli R, et al. Clin Chem Lab Med. 2006; 44(7):837–842. [LOE 4] 3. Wen WB, et al. Cell Mol Immunol. 2007; 4(3):233-236.[LOE 4] 4. American Association of Clinical Endocrinologists Thyroid Task Force. Endocr Pract. 2002; 8(6):457–469. [LOE 5]

January - March 2012

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MAFP resident grandrounds

Dermatological Manifestations of Hepatitis C virus Charles Coyne, III, MD, PGY-2 Research Family Medicine Residency Program Introduction: Hepatitis C virus (HCV) has become the most common blood-borne infection as well as the leading cause of chronic liver disease and liver transplantation in the United States. HCV transmission occurs primarily through exposure to infected blood and the infection is often asymptomatic. Only approximately one-third of patients with acute HCV have symptoms. There are several extrahepatic manifestations of chronic HCV infection including hematologic diseases, autoimmune disorders, renal disease and dermatologic conditions. For many patients, dermatological presentations may be the initial or the most apparent sign of the underlying infection. Therefore, it is important and useful to understand the cutaneous manifestations of HCV infection.

Case: A 56-year-old female presented to the hospital with shortness of air (SOA) and a skin rash. Her SOA was made worse with walking, she had no previous history of CHF and this problem was acute in nature. She also had new 3+ pitting edema in her ankles bilaterally. She described her rash as itchiness with a burning sensation of recent onset. Her past medical history included hypertension and rheumatoid arthritis. She was on Metoprolol 75 mg BID, Lisinopril 40 mg PO daily and amlodipine 5 mg daily. She had no know drug allergies and a family history significant for lung cancer in her mother. Review of systems was significant for subjective fever and minor chills, no night sweats, no cough, diarrhea, no nausea or vomiting, and no weight change. On physical exam, vital signs were temperature at 98.1, heart rate at 90, respiratory rate at 16, blood pressure was 136/50, and oxygen saturation was 99% on 2L 14 Missouri Family Physician January - March 2012

nasal cannula. She was alert and oriented while appearing obese and dyspnoeic on initial presentation. Her skin had a diffuse purpuric rash with facial and oral sparing but palmer and plantar involvement, and several guttate lesions on the extremities. The rash had a violaceous color, polygonal shape, confluent and fine diffuse scales with a leathery texture. The rash was mostly concentrated in the genital region involving the groin, anterior thighs and buttocks. No cervical or axillary lymphedema was noted. Cardiac findings revealed regular rate and rhythm with grade 2/6 systolic ejection murmur. Respiratory findings included bilateral crackles and expiratory wheeze. Initial labs reveled a WBC count of 9.7, hemoglobin of 10.5, hematocrit of 30.6, and platelets of 146,000. Electrolytes were within normal limits, aspartate aminotransferase of 54, alanine transaminase of 34 and alkaline phosphatase of 35. Brain natriuretic peptide was 2,606; cardiac enzymes were with in normal limits. Other pertinent laboratory studies showed a normal kappa lambda ratio and a negative serum protein electrophoresis. Chest X-ray showed pulmonary edema. Transthoracic echocardiogram showed EF of 65-70% with hyperdynamic LV function, and evidence of grade 2 diastolic left ventricular dysfunction. Skin biopsy was done and showed psoriasiform dermatitis epidermal changes. Hepatitis C Antibody was positive at >11.0. She was then started on treatment for hepatitis C as an outpatient and her skin condition greatly improved over the course of 3 months.

Discussion: Many extrahepatic diseases and manifestations have been associated with HCV infection. In most cases, the details of pathogenesis of these disorders remain uncertain.

It is known that the virus replicates within lymphoid cells potentially resulting in the extrahepatic manifestations. 1,2 Another theory suggests that circulating immune complexes composed of HCV antigens and antibodies deposit in tissues and cause initiation of an inflammatory cascade. Other possible mechanisms are local formation of immune complexes induced by viral antigens or local tissue inflammation induced by autoantibodies reacting with tissue antigens.1 Lazaro et al. demonstrated that HCV RNA and core proteins could be found replicating in keratinocytes.2 Proposed skin diseases resulting from HCV infection include the following: pruritus without evident skin lesions, pigmented purpuric eruption, aphthous ulcer, lichen planus, leukocytoclastic vasculitius, psoriasis, and pityriasis versicolor.3 S. Soylu et al. compared a patient group with a positive anti-HCV antibody and a control group for the presence of general dermatological findings. Forty (80%) cases in the patient group had at least one dermatological finding, whereas only 22 (44%) individuals in the control group had a dermatological findings (p<0.001).4 The risk of developing a dermatological finding was found to be increased 1.96-fold in HCV-infected patients compared with the control group (95% confidence interval 0.081-0.478).4 In several studies, pruritus was found to be strongly associated with HCV.1,2,3,4 Several skin diseases, which are all well accepted manifestations of HCV, are discussed below. Pruritus. Pruritus is a presenting symptom in 20% of patients and is associated with nonspecific lesions such as prurigo nodules and excoriations. In a Turkish retrospective case review study, generalized pruritus

resident grandrounds MAFP was observed in 13 of 70 cases (18.57%) while it was observed in only three controls (4.28%), a statistically significant difference (p<0.01).1 Similar finding were observed in the S. Soylu study of 2 groups (50 AntiHCV (+) and 50 controls) where pruritus was significant with a p-value <0.001 and an odd ratio of 0.136.4 An Egyptian retrospective case review study of 155 patients with chronic HCV showed a statistical significant correlation between having a “shrunken liver” and the presence of a dermatological manifestation, most of which was pruritus.3 Although pathogenesis is uncertain, a portion of the hepatocyte cell membrane in association with a non-bile pruritogen may be causative, acting as an opioid agonist.5 Lichen Planus. Lichen planus (LP) is seen in up to 35% of patients with chronic liver disease. Between 4-60% of cases of LP are associated with HCV, depending on the prevalence of HCV in the geographic area surveyed.6 LP is a papulosquamous disorder that may affect the skin, scalp, nails, and mucous membranes. The primary cutaneous lesions are pruritic, polygonal, flattopped, violaceous papules. Close examination of the surface of these papules often reveals a network of gray lines (Wickham’s striae). The skin lesions may occur anywhere but have a predilection for the wrists, shins, lower back, and genitalia. Oral LP (OLP) is more frequently associated with HCV.5 Lazaro et al. demonstrated that HCV infects keratinocytes from cutaneous LP lesions and the viral RNA is translated

Pic 1 - Lichen Planus

in these cells. This is demonstrated by the detection of HCV core protein in the skin biopsies of LP and OLP lesions.2 The presence of cutaneous LP and OLP can be the only presenting sign of HCV infection in asymptomatic patients. A high index of suspicion can lead to earlier diagnosis and treatment and a better prognosis from chronic hepatitis C.7 [See pic. 1] Porphyria Cutanea Tarda. Porphyria cutanea tarda (PCT) has a strong association with HCV ranging from 50-90% in multiple studies, with high geographic variance. This association involves PCT type I, the sporadic form of the disease. However, infection with HCV is much more common than PCT, and most people with HCV do not have PCT.8 PCT is recognized as the most prevalent subtype of porphyritic diseases. The disease is characterized by onycholysis and blistering of the skin in areas that receive higher levels of exposure to sunlight. The primary cause of this disorder is a deficiency of uroporphyrinogen decarboxylase (UROD), a cytosolic enzyme that is a step in the enzymatic pathway that leads to the synthesis of heme. While a deficiency in this enzyme is the direct cause leading to this disorder, there are a number of both genetic and environmental risk factors that are associated with PCT.6 Palekar and Harrison note that some researchers have suggested that HCV decompartmentalizes iron leading to the formation of free radicals and the oxidation of uroporphyrinogens. Others speculated that a decrease in the intracellular gluthione induced by

Pic 2 - Porphyria Cutanea Tarda

HCV acts as a potential trigger.8[See pic. 2] Leukocytoclastic vasculitius. Leukocytoclastic vasculitius may occur in conjunction with essential mixed cryoglobulinemia (MC). Chung et al. reported finding that HCV accounts for up to 90% of cases of MC.5 Leukocytoclastic vasculitius presents clinically with palpable purpura and petechiea that usually involve the lower extremities that are sometimes associated with polyarteritis nodosa and Reynaud’s phenomenon. In a 1995 study by Palekar and Harrison, palpable purpura corresponding histologically to leukocytoclastic vasculitius was the most frequent cutaneous involvement in patients with HCV. These patients with palpable purpura had significantly higher serum cryocrit (a measurement of cryoglobulins) levels than patients without purpura.8 Necrolytic Acral Erythema. Necrolytic acral erythema is a rare but pathognomonic finding in HCV patients. All cases to date have been associated with HCV.5 It presents as pruritic, psoriasis-like skin disease characterized by sharply- marginated erythematous to hyperpigmented plaques with variable scales and erosion on the lower extremities. In a series of 30 patients who presented with the disorder, all were found to have antibodies to HCV.9 Biopsy specimens showed psoriasiform changes, keratinocytes necrosis, and papillomatosis. Improvement was observed when the HCV was treated and subsequently relapsed in nine months after therapy was discontincontinued on page 17

Pic 3 - Necrolytic Acral Erythema January - March 2012

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resident grandrounds MAFP Resident Grandrounds continued from page 15

ued.9 This condition was very similar to the initial patient presentation from the case study. [See pic 3]

Conclusion:

HCV is associated with various dermatological disorders and patients with liver cirrhosis are at higher risk of developing lesions. In those with pruritus, HCV infection should be sought routinely as it is the most common dermatological manifestation in infected patients and the risk of development occurs early in the course of the disease. Timely intervention can stabilize the disease and positively impact morbidity and mortality. Since dermatologic manifestations may be the only and most apparent sign of chronic HCV, it is essential to recognize these dermatologic manifestations.

Fauci, Anthony S., and Tinsley Randolph Harrison. Harrison's Principles of Internal Medicine. 18th ed. New York [etc.: McGrawHill, Medical Division, 2008. Print. Maticic, M. "Lichen Planus in Hepatitis C Virus Infection: an Early Marker That May save Lives." Acta Dermatoven 16.1 (2007): 3-6. Print. Palekar, Nicole A., and Stephen A. Har-

rison. "Extrahepatic Manifestations of Hepatitis C." Southern Medical Journal 98.10 (2005): 1019-023. Print. Chopra, Sanjiv. "Extrahepatic Manifestations of HCV." UpToDate Inc. Ed. Adrian M. Di Bisceglie and Anne C. Travis. UpToDate Version 19.2, 1 Dec. 2010. Web. 25 Oct. 2011. <http://www.uptodate.com>.

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References: Dervis, E., and K. Serez. "The Prevalence of Dermatologic Manifestations Related to Chronic Hepatitis C Virus Infection in a Study from a Single Center in Turkey." Acta Dermatoven 14.3 (2005): 93-98. Print 1.

Lazaro, Pablo, Javier Olalquiaga, Javier Bartolome, Nuria Ortiz-Movilla, Elena Rodriguez-Inigo, Margarita Pardo, Manuel Lecona, Mercedes Pico, Isabel Longo, Patricia Garcia-Morras, and Vicente Carreno. "Detection of Hepatitis C Virus RNA and Core Protein in Keratinocytes from Patients with Cutaneous Lichen Planus and Chronic Hepatitis C." The Journal of Investigative Dermatology 119.4 (2002): 798803. Print. Raslan, H.M.Z, W.M. Ezzat, M.F. Abd El Hamid, H. Emam, and K.S. Amre. "Skin Manifestations of Chronic Hepatitis C Virus Infection in Cairo, Egypt." Eastern Mediterranean Health Journal 15.3 (2009): 692-700. Print. Soylu, Secil, Ulker Gul, and Arzu Kilic. "Cutaneous Manifestations in Patients Positive for Anti-Hepatitis C Virus Antibodies." Acta Dermato-Venereologica 87 (2007): 49-53. Print Chung, Connie M., and Julia R. Nunley. "Overview of Hepatitis C and Skin." Dermatology Nursing 18.5 (2006): 425-31. Print.

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MAFP wishes to recognize and thank the organizations who supported and participated in the 19th Annual Fall Conference at Big Cedar Lodge in November. Join us in expressing our appreciation to the following:

Sponsors Midwest & St. Louis District Dairy Councils Missouri Beef Industry Council Missouri Professionals Mutual (MPM) PedsPal Primaris Exhibitors Auxilium Pharmaceuticals, Inc. Barnes-Jewis Hospital Bristol Care Senior Adult Living Facilities Cox Health Docs Who Care Eli Lilly Genzyme A Company of Sanofi Glaxo Smith Kline HemoCue, Inc. Keane Insurance Group, Inc. King Pharmaceuticals Kowa Pharmaceuticals Masimo Merck Mercy Midwest Dairy Council Missouri Beef Industry Council Missouri Primary Care Association Missouri Professionals Mutual (MPM) MSMA Insurance Agency New Balance St. Louis, KC & Branson Novo Nordisk, Inc. PDS Cortex/McKesson PedsPal Pfizer, Inc.

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Submission Deadline: March 15, 2012

26 Missouri Family Physician January - March 2012

• Membership in MAFP and AAFP, with at least five years experience in family medicine • Board Certified in family medicine and/or an AAFP Fellow • Recognized by peers as an excellent physician • Socially aware & directly and effectively involved in activities that enhance the community • Provides the community with compassionate & caring medical service • Provides a credible role model as a healer to the community & as a professional in the science of medicine to colleagues, health professionals, residents, and medical students • Presents a good public image

SHOW ME FAMILY MEDICINE

ADVOCACY DAY Tuesday, February 28, 2012 Missouri State Capitol — Jefferson City Park in Madison Street Garage (enter from Madison Street)

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8:00 - 9:00am Briefing and Breakfast— Meet at MO School Boards Association (MSBA - Corner of Madison and Capitol Ave)

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9:00am Depart for Capitol (0.4 mile walk)

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9:30am Physician Volunteers needed at MAFP Booth in 3rd Floor Rotunda

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9:30am - 2:00pm Visit Legislators’ Offices (appointments to be scheduled by staff)

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11:30am Box Lunch Provided

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2:30- 6:30pm Board of Directors Meeting (Working Dinner at 5 pm) g2allery, 102 East High Street

Bring a colleague & join fellow MAFP Members (Actives, Residents, Students, etc.) to promote the importance of family medicine & primary care. This is your chance to educate your State Representative & State Senator on issues affecting you, your profession, & your patients.

Please complete return the form below to get involved.

---------------------------------------------_____ Yes, I plan to attend the MAFP Advocacy Day on Feb. 28, 2012.

Name & Designation _______________________________________________________________________ g

.or p f Voting Address ___________________________________________________________________________ o-a ation m . r ww egist e Phone _______________________ Email _______________________________________________ w r it bl Vis nline vaila o a ___ Yes, I would like a Breakfast

___ Yes, I would like a Boxed Lunch ___ Yes, I will attend the Board Meeting & Dinner Special Dietary Needs? _________________________________________________________ Please return completed form: Missouri Academy of Family Physicians, 722 W High St., Jefferson City, MO 65101, Email to office@mo-afp.org, or Fax to (573)635-0148

January - March 2012

Missouri Family Physician

It beats in every one of our member physicians. And that is why, as Missouriâ&#x20AC;&#x2122;s #1 medical professional liability insurance provider, we are proud to serve each and every one of them.

We welcome the opportunity to be of service to you. Join the team of champions. ContaCt managing direCtor timothy h. trout at 314.587.8000 or visit mpmins.Com