Fall 2019 (October-December)

FP MISSOURI FAMILY PHYSICIAN FALL 2019

VOLUME 38, ISSUE 4

THE

MENTAL HEALTH ISSUE

11.75E

NOVEMBER

MISSOURI ACADEMY OF

FAMILY PHYSICIANS STRONG MEDICINE FOR MISSOURI

CM

Annual Fall

27

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8-9 2019

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An educational program designed to enhance cognitive and procedural skills of health care professionals to help them manage obstetrical emergencies. This course is directed primarily toward maternity care providers including physicians, nurses, and certified nurse midwives.

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EXECUTIVE COMMISSION

BOARD CHAIR Sarah Cole, DO, FAAFP (St. Louis) PRESIDENT Jamie Ulbrich, MD, FAAFP (Marshall) PRESIDENT-ELECT John Paulson, DO, PhD, FAAFP (Joplin) VICE PRESIDENT John Burroughs, MD (Liberty) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS DISTRICT 1 DIRECTOR Arihant Jain, MD (Cameron)

ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Brooks Beal, DO (Kirksville)

ALTERNATE Vacant DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis)

DIRECTOR Kara Mayes, MD (St. Louis)

ALTERNATE Dawn Davis, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald)

ALTERNATE Kristin Weidle, MD (Washington) DISTRICT 5 DIRECTOR Natalie Long, MD (Columbia)

ALTERNATE Vacant DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville)

ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Wael Mourad, MD, FAAFP (Kansas City)

DIRECTOR Afsheen Patel, MD (Kansas City)

ALTERNATE Beth Rosemergey, DO, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Kurt Bravata, MD (Buffalo)

ALTERNATE Vacant DISTRICT 9 DIRECTOR Patricia Benoist, MD, FAAFP (Houston)

ALTERNATE Vacant DISTRICT 10 DIRECTOR Vicki Roberts, MD, FAAFP (Cape Girardeau)

ALTERNATE Gordon Jones, MD (Sikeston) DIRECTOR AT LARGE Jacob Shepherd, MD (Grain Valley)

RESIDENT DIRECTORS Misty Todd, MD, UMC John Heafner, MD, SLU (Alternate)

STUDENT DIRECTORS Morgan Dresvyannikov, UMKC Noah Brown, UMKC (Alternate)

AAFP DELEGATES Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE COMMUNICATIONS & EDUCATION MANAGER Sarah Mengwasser MEMBERSHIP & PROGRAMS COORDINATOR Becki Wiggins The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon.

The information contained has been provided by the individual/ organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org

CONTENTS THE

6 MENTAL HEALTH

ISSUE

7 9 12 19 22 24 27

Recognizing PTSD in Children and Adolescents LGBTQ+: Mental Health in Missouri How We Can Impact the Suicide Crisis: Best-Practice Suicidal Care in Family Medicine Disparities in Mental Disorders in the St. Louis Region Stopping Burnout at the Source: Delegating the Administrative Burden An Argument for Integrated Behavioral Health Teens, Depression, Anxiety, Suicide, and Social Media

29 Members in the News 30 New MAFP Awards 32 NCFMRS Recap 33 Composites

MARK YOUR CALENDAR Annual Fall Conference & KSA November 8-10, 2019 Big Cedar Lodge Ridgedale, Missouri MAFP Advocacy Day 2020 February 17-18, 2020 Capitol Plaza Hotel/ Missouri State Capitol Jefferson City, Missouri

Show Me Family Medicine Conference 2020 June 12-13, 2020 Margaritaville Lake Resort Lake Ozark, Missouri

Pay Your Dues for 2020 www.aafp.org

MO-AFP.ORG 3

A Letter From the Chair o much conversation today centers around physician wellness, burnout, and mental health. This issue of Missouri Family Physician focuses also on the well-being and mental health of the people we serve as family physicians. Research helps us understand who may be more likely to suffer mental health disorders, and effective ways in which to alleviate that suffering.

I thank our contributors for their work regarding specific populations at higher risk for mental health complications, and invite our members to learn from their submissions.

As you read this issue, keep in mind that we are moving toward adding a peer-reviewed component to MAFP newsletters. If you are interested in volunteering as a peer reviewer, please contact Sarah Mengwasser at smengwasser@mo-afp.org.

MAFP is also working toward action on its 20182021 strategic plan, including empowerment of its

s Sarah Cole, DO, FAAFP MAFP Board Chair

political action committee. In these contentious times, it is important that MAFP maintain its own voice to speak on behalf of its members.

You may be asked by former Board Chair, Dr. Mark Schabbing, to consider a donation to the MAFP PAC. I urge you to not only donate financially but also intellectually! MAFP is seeking the most effective way to discern the opinions of its members on advocacy issues. Let us know your stance on these issues by participating in member surveys or by contacting MAFP staff directly at office@mo-afp.org or (573) 635-0830.

Alternatively, tell us in person when you join us at the Annual Fall Conference at Big Cedar Lodge in Ridgedale, Missouri (near Branson) November 8-10.

Board members will be intentionally reaching out to attendees for their insights on how MAFP can best meet the expectations of Missouri’s family doctors!

Elevating the industry When you always put policyholders first, there’s no limit to how high you can go.

magmutual.com/innovation

4

MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019

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800-282-4882

MISSOURI ACADEMY OF FAMILY PHYSICIANS'

Advocacy Day Register at mo-afp.org

2020

You are the Voice of Missouri Family Physicians

February 17-18

Capitol Plaza Hotel and Missouri State Capitol, Jefferson City, MO Monday, February 17 6:30 am – 8:30 pm Legislative Briefing of Key Issues and Buffet Dinner, Capitol Plaza Hotel Tuesday, February 18 8:00 am – 1:00 pm Legislative Briefing and Breakfast, Capitol Plaza Hotel Visit Legislators’ Offices (appointments to be scheduled for you by MAFP staff)

(Lunch buffet at hotel) 1:30 – 4:00 pm Board of Directors Meeting NEW THIS YEAR -- Can’t attend? We’ve got you covered…there is an opportunity for you to participate and make your voice heard. We will be offering a live feed of Monday evening’s detailed legislative briefing through Zoom – but you will still need to register so we can plan accordingly.

AND…we will have an opportunity for you to contact your legislators through a Speak Out portal. We will craft a message for you to use, or create your own.

Calling all Medical Schools and Residency Programs – Send a group of students or residents to attend this year’s important legislative meeting. Let’s show our legislators that we are united and serious about taking care of our patients and protecting the scope of practice for family physicians. *A limited number of complimentary sleeping rooms are available through the MAFP. Contact Kathy Pabst at kpabst@mo-afp.org or call 573.635.0830 for more information and availability.

MO-AFP.ORG 5

"

MENTAL health HEALTH THERE'S

NO

WITHOUT

David Satcher 16th Surgeon General of the United States

6

"

The information contained in Missouri Family Physician is for informational purposes only.

The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon.

The information contained has been provided by the individual/organization stated.

The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019 no responsibility for the opinion expressed thereon.

Member Opinion

Recognizing PTSD in Children and Adolescents ccording to researcher Katie McLaughlin, PhD., 62% of youths experience at least one traumatic event in their lifetime; 19% have experienced three or more traumas. Given the recent focus on Adverse Childhood Experiences (ACEs) and the need to include screening for ACEs during routine wellness exams, it makes sense to become more familiar with the diagnosis of Post-traumatic Stress Disorder (PTSD). PTSD is a severe, often chronic, anxiety-based disorder that has a lifetime prevalence of 5% in the general youth population. A diagnosis of PTSD requires the presence of a known etiologic factor -- the trauma that precipitated the symptoms. The trauma may involve actual or threatened injury to themselves or others. If a clinician has suspicion of trauma exposure, but no confirmation, the child should be referred for further psychological evaluation.

A diagnosis of PTSD is not made until the child has manifested symptoms for at least one month; prior to this, a diagnosis of Acute Stress Disorder or Adjustment Disorder with anxious symptoms should be utilized. If symptoms persist beyond three months of the diagnosis, they are considered chronic. PTSD symptoms must also cause clinically significant distress or impairment and cannot be the result of substance use or another medical condition. Because panic symptoms in the immediate aftermath of the trauma may predict PTSD in children, it is important to evaluate for panic in the acute stage.

In addition to the presence of a trauma, the diagnosis of PTSD requires symptoms from four distinct groups including: 1) intrusive symptoms, 2) persistent avoidance of trauma reminders, 3) negative alterations in cognition and mood, and 4) marked alterations in arousal and reactivity.

Intrusion symptoms include such complaints as recurrent and intrusive memories of the trauma, nightmares related to the trauma or frightening dreams in children 6 or younger, a sense of reliving the trauma in the form of flashbacks, dissociative symptoms, and intense or prolonged distress at exposure to cues that resemble the trauma.

Dissociative symptoms include depersonalization (feeling detached from one’s body, a sense of unreality of self) and derealization (a sense of

a

unreality of surroundings). In children age 6 or younger, intrusive symptoms may appear as repetitive play in which the traumatic themes are expressed or reenacted. Symptoms from the avoidance group would include efforts to avoid either internal reminders such as memories, thoughts, and feelings or external reminders, such as people, places, conversations or objects associated with the trauma. The third group of symptoms which describe negative alterations in cognitions and mood include the inability to recall important aspects of the trauma, persistent and exaggerated negative beliefs about themselves, persistent and distorted thoughts about the cause or consequences of the trauma that lead the child to blame themselves or others, persistent negative emotions, a decreased interest in activities the child previously enjoyed, detachment, and a persistent inability to experience positive emotions. The last group of symptoms involve changes in arousal and reactivity and includes behaviors such as difficulty falling or staying asleep, irritability, angry outbursts, self-destructive behavior, poor concentration, hypervigilance and an increased startle reaction. In younger children, one may observe the onset of new aggressive acts, oppositional behavior, new fears including a fear of separation, and regression in developmental skills. PTSD may present with somatic complaints such as headache and abdominal issues; consider a mental health assessment in children presenting with multiple somatic complaints following known traumatic exposure.

Risk factors for the development of PTSD include: interpersonal violence (sexual and physical abuse), female gender, a higher number of traumatic experiences, preexisting psychiatric disorders, parental psychopathology and a lack of social support. Conversely, protective factors include: parental supports and lower levels of parental PTSD. Some additional risks include: increased television viewing of the disaster or traumatic event, delayed evacuation from a trauma; extreme panic symptoms have independent risk for the development of PTSD. A differential diagnosis for PTSD includes: attention-deficit hyperactivity disorder, oppositional defiant disorder, panic disorder,

Kyle S. John, MD Dr. Kyle John is a board certified child and adolescent psychiatrist at Mercy’s Virtual Care Center in St. Louis, Missouri. He is a distinguished fellow of the American Academy of Child & Adolescent Psychiatry, and has practiced at Mercy for 13 years.

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"

Primary care physicians are encouraged to screen children and adolescents for ACEs at all routine wellness exams."

major depression, disruptive mood dysregulation disorder, bipolar disorder, substance-use disorder, psychotic disorder and delirium. Medical illnesses which produce PTSD-like symptoms include: hyperthyroidism, caffeinism, migraine, asthma, seizure disorder and catecholamine & serotoninsecreting tumors. Medications whose side effects may mimic PTSD include: antiasthmatics, sympathomimetics, steroids, SSRI’s, antipsychotics, diet pills, antihistamines and cold medicines.

The course of PTSD is highly variable, with 2/3 of patients reaching recovery while 1/3 experience a more chronic course. Treatment consists of traumafocused therapy (child-parent psychotherapy/ CPP, Cognitive-Behavioral psychotherapy/CBT, and eye movement desensitization and reprocessing/ EMDR) which can be delivered individually, in a group and even at school. If the child’s response to therapy is inadequate, the use of anti-anxiety medications may be considered for use in an off-label manner, including alpha-adrenergic 8

MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019

blockers (clonidine, guanfacine, prazosin), selectiveserotonin reuptake inhibitors, and hydroxyzine. If untreated, PTSD often leads to the development of other mental disorders, suicide, impairment in role functioning, reduced social and economic opportunity, and the earlier onset of chronic medical diseases.

Primary care physicians are encouraged to screen children and adolescents for ACEs at all routine wellness exams, including the use of the Adverse Childhood Experience Questionnaire.

Visit the CDC website for more information about screening for and treatment of ACEs at https://www.cdc.gov/violenceprevention/ childabuseandneglect/acestudy/index. When patients are identified with higher ACEs scores, use the PTSD screening tool, https://www.aacap. org/App_Themes/AACAP/docs/resource_centers/ resources/misc/child_ptsd_symptom_scale.pdf, along with the four domains of symptoms, to make an accurate diagnosis, before referring for therapy.

Non-Member Opinion

LGBTQ+: Mental Health in Missouri

"

t is estimated that there are nearly 200,000 self-identified LGBTQ+ (lesbian, gay, bisexual, transgender, queer) individuals residing in Missouri, which equates to approximately 4% of the total population of the state (Movement Advancement Project <MAP>, 2018). This number is likely higher in reality due to the stigma, and potential danger, that still exists in many places against openly LGBTQ+ individuals who may be fearful of identifying themselves. Minority stress posits that any marginalized minority population will inherently have higher levels of mental health struggles due to both perceived and real discrimination and trauma, and that the marginalization they experience is structural and systemic. All of which compounds the intensity of general life stress. Multiple studies have shown this to be true for the LGBTQ+ population. Gay men historically have experienced significantly higher rates of clinical depression and anxiety than their heterosexual peers, which naturally leads to higher rates of drug and alcohol abuse, smoking, high risk sexual behaviors, and reported loneliness and isolation. Lesbians tend to experience elevated rates of violence and sexual assault than heterosexual women, as well as higher levels of obesity and smoking, and less preventative care.

Both lesbians and gay men generally report higher levels of PTSD symptomology, and LGB young people (ages 10-24) are five times as likely to have attempted suicide than their heterosexual peers; and their attempts tend to be more violent and require medical care more often than heterosexual suicide attempts (The Trevor Project, 2016).

While these numbers are alarming, for transgender and gender non-conforming (TGNC) individuals, they are significantly worse. The Southern Poverty Law Center (2015) reports that transgender women of color are the most at-risk and victimized minority population in the United States. TGNC individuals are four times more likely to live in poverty with household incomes under $10,000 than non-TGNC individuals, and TGNC adults attempt suicide at a rate of 41% (versus 1.6% of the non-TGNC population) (The Trevor Project, 2016).

i

Creating specific policies around how to address and treat LGBTQ+ patients places the onus on the providers to address disparities in healthcare rather than the patient."

Ryan S. Cox, PhD Dr. Ryan Cox is a licensed clinical psychologist in Missouri, and currently serves as the Chief of Psychology in the Family Medicine Residency Training program at Truman Medical Center in Kansas City.

In general, sexual and gender minorities report more hopelessness, rumination, social isolation, and trauma compared to heterosexuals and cisgender individuals, which leads to higher levels of health risk behaviors, and less preventative care. Healthcare facilities can rank among the most structurally and systemically discriminatory places most of us will experience, and there are a multitude of reasons for this. Very little is taught in most medical schools regarding diversity, minority stress, and assessing for social, and I would argue emotional, determinants of health.

Even less is generally taught about mental health care, and practicing in a trauma-informed way.

Often in medical facilities, there is an operational neutrality and (hopefully) benign ignorance about the unique needs facing this population, as if major aspects of a personâ&#x20AC;&#x2122;s identity and lived experience have no bearing on their health outcomes. For instance, up to 70% of TGNC individuals report being discriminated against in a healthcare setting.

This ranges from substandard care, to verbal or physical abuse, invasive and irrelevant questions,

MO-AFP.ORG 9

being treated disrespectfully, and sometimes even overtly refused care. Many LGBTQ+ individuals have an understandable reluctance to go to the doctor, and oftentimes even more reluctance to talk about mental health struggles they may be experiencing, because they may be too closely tied to a gay, lesbian, or TGNC identity they may not feel comfortable revealing. In metropolitan areas like Kansas City and St. Louis, there may be more options for some people who have the means and resources to find and pay for them, but for many Missourians, there may be only one, or very few providers they can go to.

In 2018, under the guidance of President Trump, the U.S. Department of Health and Human Services announced it planned to roll back two regulatory guidelines protecting LGBTQ+ people from discrimination in healthcare. The first would allow much broader religious exemptions in healthcare law, making it much easier for providers and insurance companies to deny care to anyone they choose, citing religious or moral beliefs.

The second would reverse an Obama-era law protecting individuals in healthcare settings against discrimination based on gender identity. Only 13 states currently have laws explicitly protecting individuals from healthcare discrimination based on sexual orientation or gender identity (Human Rights Watch, 2018). In Missouri it is still perfectly legal for any provider to refuse service to an LGBTQ+ person based on their personal beliefs. These kinds of laws, or lack thereof, tend to have a chilling effect on peoples’ utilization of healthcare, and their comfort with being open with their providers about any concerns they may have, particularly as it relates to mental health. Already, many people perceive a stigma around mental health concerns, but when you are also a member of a stigmatized population, that shame can be compounded by fear of discrimination or judgment.

It is estimated that nearly half of the mental health treatment in the United States is delivered by primary care providers (National Institute of Mental Health, 2017), placing them on the frontlines of both preventative and reactive mental healthcare. It is imperative that providers begin to understand the barriers that face LGBTQ+ people accessing healthcare and how they can help.

Developing policies in your workplace to recognize and protect LGBTQ+ patients and employees is a good place to start. Some organizations resist these policies on the basis of a neutrality that purports to treat all people equally. But what that misses are the unique life experiences and contexts in which all of our 10

MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019

patients and employees live. Creating specific policies around how to address and treat LGBTQ+ patients places the onus on the providers to address disparities in healthcare rather than the patient. Some examples of this may include providing more options than simply Male or Female on intake paperwork. Adding Transgender, or more specifically, Transgender Man or Transgender Woman, can let patients know you are aware they exist, this is something you think about, respect, and that you are not afraid to talk about these issues. Further, overtly asking about sexual orientation and sexual behaviors removes the pressure from patients to self-disclose in an environment where they may not know if it is safe to do so. Utilizing gender neutral language is a subtle but effective method of conveying your cultural competence around LGBTQ+ identities.

If a person in front of you appears to be male or female, instead of enquiring about his wife or her husband, ask about a spouse or partner. Instead of assuming someone’s gender identity if you do not know, use the gender neutral pronoun “they.”

Often extra training is required for providers and front line staff to implement these policies, but once in place, they make the environment safer and more inclusive for all patients and employees, not just LGBTQ+-identified individuals.

Secondly, educate yourself on resources available to your LGBTQ+ patients if they share with you that they are struggling. This is an area where networking and talking openly about these kinds of issues with your colleagues can be helpful in identifying safe and affirming places to refer your patients for mental health, social, or medical support. If none exist in your area, even just being one safe person they can open up to can be helpful.

One blessing of the internet is that it opens up so many communities to people that might not otherwise have access to them. But nothing replaces in-person support and care, and having a physician in their corner could mean the world to someone that is struggling.

Lastly, and perhaps most importantly, explore your own biases, challenge yourself, and educate yourself. Seek out resources and understanding.

Provide for trainings in your facility, or seek out workshops or lectures at conferences, and share the information with your colleagues. So often when it comes to issues of diversity, we have internalized biases impacting us that we may not even be aware of. We may intellectually believe one thing, but have an emotional response that is incongruent with our stated belief system. This emotional, or knee-jerk response can impact

patient care more than anything. As competent and affirming practitioners, it is our duty to understand our own biases and work toward eradicating or changing them.

For many people, talking to a healthcare provider can be one of the most intimidating experiences there is. When someone is part of a minority group that is frequently discriminated against or has historically been abused or neglected by the medical profession, it can intensify that fear and anxiety. We must use our privilege and our power to advocate for those who have less of both, and to be true allies in the fight for equity and resources.

References and Resources Becerra-Culqui, T. A., et al. (2018). Mental health of transgender and gender nonconforming youth compared with their peers.

Pediatrics, 141.

The Center of Excellence for Transgender Health – University of California San Francisco. https://prevention.ucsf.edu/transhealth Human Rights Watch (2018, July 23). US: LGBT people face healthcare barriers. Retrieved from https://www.hrw.org/ news/2018/07/23/us-lgbt-people-face-healthcare-barriers

Today

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

Stop kids from starting.

Volunteer to be a Tar Wars presenter.

Movement Advancement Project (2018). Missouri’s Equality Profile. Retrieved from https://www.lgbtmap.org/equality_ maps/profile_state/MO National Institute of Mental Health (2017, February). Integrated care. Retrieved from https://www.nimh.nih.gov/health/topics/ integrated-care/index.shtml Pachankis, J.E., et al. (2015). LGBT-affirmative cognitive behavioral for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach.

Journal of Consulting and Clinical Psychology, 5, pp. 875-889.

Stall, R., et al. (2016). The continuing development of health disparities research on gay, lesbian, bisexual and transgender individuals. American Journal of Public Health, 5, pp.787-789.

Su, D., et al. (2016). Mental health disparities within the LGBT population: A comparison between transgender and nontransgender individuals. Transgender Health, 1, pp. 12-22.

The Trevor Project (2019). Facts about suicide. Retrieved from https://www.thetrevorproject.org/resources/preventingsuicide/facts-about-suicide/

www.tarwars.org

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

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Member Opinion

How We Can Impact the Suicide Crisis: Best-Practice Suicidal Care in Family Medicine suicide death brings devastation to families, communities and providers. I learned this when I lost my only child to suicide. I am sharing what I wish I knew then to help others avoid this suffering.

As family physicians, our patients come to us for most, if not all, of their health care needs.

Suicide prevention is everybody’s business and very appropriately belongs in the family physician’s realm. To help reduce this escalating, preventable cause of death, we need to get comfortable with Beth Zimmer, MD the topic of suicide, address our own perspectives and prejudices, perform universal screening and Beth Zimmer, MD, LTC know best practice assessment and management of (Ret) U.S. Army Reserves, the suicidal person. (1) is board certified in family In Missouri, suicide rates have increased at medicine and has practiced an alarming 40% over the last decade. Suicide is in St. Charles, Missouri for now the most common cause of death in those over 30 years. She lost her ages 10-17 and the second most common cause only child, Army Airborne Ranger Christopher Carter, of death in ages 18-34. Suicide deaths rank in the to suicide in 2015. Dr. top ten causes of all death (sixth in males). (2;3) Zimmer has made it her Missouri positions 18th in suicide rates in the USA. mission to learn and share (4). Suicide cuts across all socioeconomic levels, current best practice suicide geographic locations, ages, ethnicity, race, and prevention expertise. gender.

Approximately 4% of all adults and 9% of young adults have serious suicidal thoughts. 1 in 200 adults and 1 in 55 young adults attempted suicide in 2016. In adolescents, almost 1 in 5 have suicidal ideation and 1 in 13 adolescents attempt suicide annually. (5) Almost two-thirds (64%) of those who die by suicide saw a medical provider within their last month (45% saw their primary care provider) and 38% visited a medical provider within the week prior to their death. Most of these visits were NOT for mental health reasons. (6) Less than half of those who die by suicide have been diagnosed with a mental health disorder. (7) We cannot assume

a

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all those who will attempt suicide have a mental health diagnosis and even those who do may be much more willing to discuss their suicidal thoughts with their trusted family doctor than a mental health specialist. In addition, access to mental health professionals are often not timely and can be fraught with many barriers. Missouri ranks as the 35th state in access to mental health rating. (8) Therefore, family physicians need to get familiar with best practice suicide prevention, risk factors, and evidence-based interventions, if we want to save our patient's lives.

Many factors contribute to suicide among those with and without mental health conditions. Suicide is the result of a complex combination of biological factors including genetics, psychiatric illness and brain injury, combined with situational stressors and a person’s ability to cope. Suicide typically does not result from a single bad event. However, a particularly stressful experience can be the tipping point for someone already at high risk. (9) Suicide feelings are often transient and can come and go rapidly. Most suicide attempt survivors will state they really did not have the desire to die, but rather the strong desire to end their internal pain.

They had reached a point where their pain became so unbearable and their hopelessness so complete, they could see no other way out. They develop a type of “tunnel vision.” There is often still an internal conflict of wanting to live but an inability to see any other resolution to their pain. It is this ambivalence about dying that can often be used to help convince them to hold on. (10) Thomas Joiner, considered one of the leading experts in suicidology, proposes a theory that suicide results from the combination of the necessary psychological states of mind (perceived burdensomeness and isolation) coupled with the ability to follow through with the act. This ability

is obtained either through direct exposure to pain and death such as experienced by soldiers, firstresponders and physicians, or through repeated attempts. (11) Being aware of the warning signs and behaviors indicating potential suicidal activity is akin to knowing the warning signs of a potential heart

"

Suicide is preventable and we can turn around this devastating trend, but we need everyone doing their part."

attack, such as chest pressure or shortness of breath. (Figure1). One of the most significant suicide warnings is talking about wanting to die or to kill oneself. We should never consider any suicide threat as a “gesture” or simply an attention seeking behavior. 70% of those who complete suicide communicated their intentions or wish to die to significant others. Any reference to suicide should serve as a reason to further assess and, at the least, an opportunity to get early intervention.

There may be an increase or unusual preoccupation with death or dying and seeking ways to kill oneself, such as researching on the internet, buying a gun, or stockpiling pills. Giving away valued possessions, saying “good-bye” either by texting, calling, visiting, or posting on social media is a worrisome warning.

One may talk about feeling hopeless or having no reason to live or feeling trapped or in unbearable pain. Speaking about being a burden to others is another clue. A suicidal person often withdraws or isolates and may increase the use of alcohol or drugs. Beware of rapid, extreme mood changes

from a severe depression or agitation to a peaceful state; this may indicate a calming acceptance of a conclusive decision to end one’s life.

To continue the cardiac analogy, just as there are multiple risk factors of heart disease such as family history and lifestyle factors, there are also multiple factors which increase the risk of suicide.

A previous suicide attempt is the highest risk predictor. Patients who have attempted suicide are double the risk of completing suicide, especially during the following three months. Depression, anxiety including PTSD, insomnia, traumatic brain injury, and substance use disorders greatly increase the risk. Traditionally, clinicians have focused on treating the underlying behavioral health disorder in suicidal patients but have not directly addressed the suicide risk. Providing direct treatment of suicide risk using evidence-based interventions, in addition to treating the behavioral health condition, is vital.

A relationship loss or other recent or anticipated event leading to shame, despair or humiliation is associated with over 40% of suicide deaths. Family history has been found to increase the risk by both genetic and environmental manners. Exposures to others who have died by suicide either personally or through the media heightens risk. We will sometimes see communities experience a cluster of completed suicides, a sense of “contagion,” that influences others. Childhood abuse (including bullying and cyber bullying), domestic abuse and exposures to violence raises risk. Those struggling with LGBTQ identity challenges, and those having a major chronic illness or a recent serious diagnosis, especially an illness associated with pain, have increased risk. Unstable finances, lack of health care, especially mental health care, and lack of substance use treatment increases the risk.

Military Veterans have a highly disproportionate rate of suicide. Easy access to lethal means (firearms) is its own risk factor. Firearms account for the majority of deaths by suicide. (12) A recent discharge from a mental health facility is a marked high-risk time, increasing risk approximately 15 times. During this very vulnerable time for our patients, are we networking with our behavioral health colleagues and facilities to follow up, just as we would those discharged from an emergency department or in-patient facility for physical reasons?

Traits of perfectionism, pressure to perform, and those who harbor stigma associated with behavioral health care are also at risk. Physicians are one of the least likely groups to get mental health support, yet have a much higher rate of suicide than the general population, with male MO-AFP.ORG 13

physicians having 1.4 times and female physicians 2.3 times the national suicide risk. (14) The National Action Alliance of Suicide Prevention Task Force in 2010, developed a model based on health care programs that have reduced suicide rates in their organizations. They call this initiative Zero Suicide. “Zero Suicide" is not only an aspirational goal, it offers a practical framework for transforming suicide prevention in health care systems. Institutions that have embraced the Zero Suicide Model have shown up to 70% reduction in suicide attempts. (15) A patient generally will not spontaneously report that he/she is feeling suicidal, but the majority will admit to suicidal thoughts when nonjudgmentally asked. Contrary to a commonly held perception, talking about suicide does not increase the risk of suicide. Being able to express suicidal feelings to a sympathetic listener has been found to be therapeutic and reduce risk. (16) Often, a suicidal patient will need to talk and vent about recent life events. When possible, and always with children and adolescents, seek to confirm the information you obtain from the patient with additional information from a family member or close friend. Broach the topic directly, openly and nonjudgmentally. We need to monitor our own unease and avoid implying a negative response.

Support the patient’s expressions of feelings as normal and valid, and emphasize that his/ her feelings are neither good nor bad. A suicidal patient frequently has a personal negativism; his/ her feelings are distorted, and will often truly feel the world would be better off without him/her. To not add to the personal negativism, avoid lecturing on the value of life or how his/her death would negatively affect others. However, it is important to offer hope. Hope is the antidote to suicide. (17) Support in the moment and show you care. Let him/her know these feelings are usually temporary and can be cured.

Screening for suicide should be completed at all medical visits using a validated tool. This is the recommendation of the Joint Commission. A large emergency department study showed a 30% reduction in suicides using universal screening with a brief intervention and follow up contact.

(18) Joint Commission Sentinel Event Alert Issue 56 recommends the following actions for medical personnel. (19) 1. Review each patient’s personal and family medical history for suicide risk factors.

2. Screen all patients for suicide ideation, using a brief, standardized, evidence-based screening tool. This can be delivered either as a waiting room questionnaire or a personally directed 14

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survey that includes a question specifically asking if the patient has had thoughts about killing him/ herself. Research shows that a brief screening tool can identify individuals at risk for suicide twice as often as leaving the identification up to a clinician’s personal judgment or by asking about suicidal thoughts using vague or softened language. The Patient Health Questionnaire (PHQ-9) is one of the more commonly used and validated screeners.

(20) Some practices use the shorter version, the PHQ-2, which asks two questions about depression symptoms. If the PHQ-2 is positive (greater than 2), then the full PHQ-9 is administered.

Some practices add an additional question to the PHQ-2 / PHQ-9 about suicidal thoughts and feelings, including past attempts, which has been found to be the most predictive identifier. (21) 3. Review screening questionnaires before the patient leaves the appointment or is discharged.

If a patient’s answer is “yes” to any of the suicidal questions, or your suspicion is high, immediately conduct or refer for a more in-depth secondary suicide risk assessment. Tools such as the Columbia Suicide Severity Rating Scale (22) or the Suicide Prevention Resources Center’s SAFE-T can be used for more in-depth identification and assessment of a patient’s suicide risk and protective factors. The SAFE-T resource, with an imbedded mental health provider finder, can also be downloaded as a phone app. (23) Using tools are important as clinicians frequently underestimate or downplay a patient’s suicide risk.

For patients who screen positive and then deny or minimize their suicide risk or who decline treatment, obtain corroborating information by requesting the patient’s permission to contact friends, family, or outpatient treatment providers.

If the patient declines consent, HIPAA permits a clinician to make these contacts without the patient’s permission when the clinician believes the patient may be a danger to self or others.

4. Use assessment results to determine the level of safety measures needed and immediately take the following actions.

Provide a high-risk patient immediate access to care through an emergency department or an inpatient psychiatric unit. An example of a high-risk suicidal situation that may need to be hospitalized includes a patient with severe psychiatric symptoms, an acute precipitating event, and access to lethal means, especially if the patient has poor social support. Do not leave a patient in acute suicidal crisis alone, keep in a safe health care environment under one-to-one observation. All acutely suicidal patients, including children, should be transported by ambulance or professionals.

"

Physicians have higher rates of suicide and symptoms of depression than the general population, and at the same time are less likely to seek mental health treatment.

400 physicians per year take their own life.

Caring for others is fatiguing; in order to give our patients what they deserve, we must be attentive to ourselves and our fellow providers and co-workers, especially after the loss of a patient or someone close to us.

“Practice what you preach” and model good self-care.

Emergency care and/or hospitalization may be necessary for a patient’s immediate safety. However, hospitalization used solely as a containment strategy or to appease a clinician’s personal anxiety, may be ineffective or counterproductive and considered by the patient as a disincentive or penalty for expressing suicidal thoughts. (24) For patients at lower risk of suicide, make personal and direct contact or referral to outpatient behavioral health providers for follow-up care within one week of initial assessment, rather than leaving it up to the patient to make the appointment. (25) As behavioral health referrals are not always readily available, follow up appointment(s) with the primary care provider may be necessary in the interim to monitor his/her status and update level of risk. In addition to management of any underlying psychiatric diagnosis, modifying risk and enhancing protective elements, evidence-based psychological approaches that help to reduce suicidal thoughts and behaviors include: 1) Cognitive Therapy for Suicide Prevention, (CBT) (27) the Collaborative Assessment and Management of Suicide (CAMS) (28) and Dialectical Behavior Therapy (DBT). (29) For all patients with suicide ideation: • Give every patient and his/her family or friends the National Suicide Prevention Lifeline, 1-800-273TALK (8255). This national number routes to the nearest accredited crisis resource. Counselors at

these centers are skilled in suicide crisis intervention and have access to information about many local resources for individuals contemplating suicide. It is also recommended you have materials available in your office about local crisis center services, alcohol and drug treatment programs, etc.

• Conduct Safety Planning by collaborating with the patient to identify his/her possible coping strategies and by providing resources. Safety Planning has been shown to be an effective intervention and is accomplished by first recognizing his/her personal signs of an approaching crisis, then identifying coping strategies and social contacts that could help distract or assist. The intent is to have a preprepared, personal plan of resources available before a crisis. (30) A safety plan is not a “no-suicide contract” or “contract for safety” which is NOT recommended by experts in the field of suicide prevention. (31) A sample Safety Plan (28) is included in Figure 2. These can be downloaded and kept convenient. Multiple phone apps are also available for Safety Planning. Some include direct call/ text routing to contacts in a crisis. When possible, involve significant other(s) in the intervention and the planning and ensure they are aware of their role and resources. Re-evaluate the patient’s suicide risk at every interaction and review the safety plan until the patient is no longer at risk for suicide.

• Restrict access to lethal means. Suicidal thoughts MO-AFP.ORG 15

can come and go rapidly, restricting or slowing • Be aware of your own emotional reactions access either by time or space is lifesaving. Assess and distress when confronting others’ traumatic whether the patient has access to firearms or other experiences. lethal means, such as prescription medications • Connect with others by talking about your or chemicals. Every patient with suicidal ideation reactions with trusted colleagues or others. should have a safety discussion, including firearm • Maintain balance between your professional safety, even if that is not the method the patient and personal life with a focus on self-care. has identified. Taking the time to respectfully Suicide is often discussed in the context of screen and discuss firearm safety with any mental illness, and suicide prevention is an issue depressed patient is warranted as many suicides that behavioral health providers should address. occur with little planning during a crisis. (32) The (37) However, given that mental health conditions Harvard T.H. Chan School of Public Health’s Means are only one of many factors that contribute to Matter website provides helpful advice on means suicide risk, it is incumbent that all healthcare restriction. (33) sectors adopt evidence-based approaches to • A follow up “Caring Contact”, which is a identify and care for those at risk for suicide. subsequent connection demonstrating care Suicide is preventable and we can turn around this and concern has been shown to reduce suicide devastating trend, but we need everyone doing risk. Research endorses these supportive their part. communications and can be automated and effective via postcards, letters, e-mail, text messages or phone calls. (34) With higher risk Figure 1. Warning Signs and Alarming Behaviors (save.org) patients, it is recommended to establish direct contact office protocols to follow up, especially Warning Signs during provider or facility transitions and if The warning signs of suicide are indicators appointments are missed. (35) that a person may be in acute danger and may 5. Be sure to record risk assessment, rationale, urgently need help. and treatment plan in the patient’s record. Update problem list entries, follow-up contacts, and • Talking about wanting to die or to kill oneself collaboration with other providers to assist in the • Looking for a way to kill oneself patient’s continuity of care.

• Talking about feeling hopeless or having no We worry about setting ourselves up for a purpose liability, but “don’t take a temperature, you may • Talking about feeling trapped or being in find a fever” or “didn’t ask/didn’t tell” are not unbearable pain defendable arguments. The best defense against a • Talking about being a burden to others claim of suicide malpractice is a well-documented • Increasing the use of alcohol or drugs clinical interview using evidence-based, best • Acting anxious, agitated, or reckless practice protocols of screening, assessment, safety • Sleeping too little or too much planning and documentation.

• Withdrawing or feelings isolated Physicians have higher rates of suicide and • Showing rage or talking about seeking symptoms of depression than the general revenge population, and at the same time are less likely to • Displaying extreme mood swings seek mental health treatment. 400 physicians per year take their own life. (36) Physicians are even more prone to the stigma surrounding mental health care, and report time constraints and concerns about reputation and confidentiality as additional barriers to seeking treatment. Caring for others is fatiguing; in order to give our patients what they deserve, we must be attentive to ourselves and our fellow providers and co-workers, especially after the loss of a patient or someone close to us. “Practice what you preach” and model good self-care. (36)

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Figure 2. Safety Plan (Brown-Stanley)

Patient Safety Plan Template Step 1:

Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be developing:

1. _____________________________________________________________________________________________ 2. _____________________________________________________________________________________________ 3. _____________________________________________________________________________________________ Step 2:

Internal coping strategies â&#x20AC;&#x201C; Things I can do to take my mind off my problems without contacting another person (relaxation technique, physical activity):

1. _____________________________________________________________________________________________ 2. _____________________________________________________________________________________________ 3. _____________________________________________________________________________________________ Step 3:

People and social settings that provide distraction:

1. Name____________________________________________________ Phone______________________________ 2. Name____________________________________________________ Phone______________________________ 3. Place__________________________________________ 4. Place______________________________________ Step 4:

People whom I can ask for help:

1. Name____________________________________________________ Phone______________________________ 2. Name____________________________________________________ Phone______________________________ 3. Name____________________________________________________ Phone______________________________ Step 5:

Professionals or agencies I can contact during a crisis:

1. Clinician Name____________________________________________ Phone______________________________ Clinician Pager or Emergency Contact # _________________________________________________________ 2. Clinician Name____________________________________________ Phone______________________________ Clinician Pager or Emergency Contact # _________________________________________________________ 3. Local Urgent Care Services______________________________________________________________________ Urgent Care Services Address___________________________________________________________________ Urgent Care Services Phone_____________________________________________________________________ 4. Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255) Step 6:

Making the environment safe:

1. _____________________________________________________________________________________________ 2. _____________________________________________________________________________________________ Safety Plan Template Š2008 Barbara Stanley and Gregory K. Brown, is reprinted with the express permission of the authors. No portion of the Safety Plan Template may be reproduced without their express, written permission. You can contact the authors at bhs2@columbia.edu or gregbrow@mail.med.upenn.edu.

The one thing that is most important to me and worth living for is: ________________________________________________________________

Resources National Suicide Lifeline: 1-800-273-8255 Primary Care Toolkit http://www.sprc.org/settings/primarycare/toolkit Quick Guide for Clinicians http://www.sprc.org/sites/default/ files/PCPocketCard.pdf Columbia Suicide Severity Rating Scale http://cssrs.columbia. edu/ SAFE-T card guides clinicians through five steps which address the patient's level of suicide risk and suggest appropriate interventions. http://www.sprc.org/resources-programs/ suicide-assessment-five-step-evaluation-and-triage-safe-tpocket-card Means Matter website https://www.hsph.harvard.edu/meansmatter/ Counseling Advice on Lethal Means (CALM) https://go.edc.org/ CALMonline Safety Planning: http://www.sprc.org/resources-programs/ patient-safety-plan-template References (1) Rosenberg L. Suicide Prevention is Everyone’s Business. J Behav Health Serv Res. 2018 Oct;45(4):530-532.

(2) Ten leading causes of death by age group, United States, 2017. Web-Based Inquiry Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. www.cdc.gov/nchs 2017 (3) Infographic. https://wonder.cdc.gov/wonder/help/mcd.html (4) CDC. FastStats - Death and mortality. www.cdc.gov/injury 2017 (5) Substance Abuse and Mental Health Services Administration. www.samhsa.go/data/sites (6) Ahmedani, BK, et. al: Health care contacts in the year before suicide death. Journal of General Internal Medicine 2014.26(6):870-877.

(7) Luoma, JB, Contact with mental health and primary care providers before suicide. Am J Psychiatry, 2002, Jun: 15(6).

909-16.

(8) www. Mentalhealthamerica.net/issues/2017 – state-mental health America-access-care-data Suicide statistics.

(9) American Foundation for Suicide Prevention. https://afsp. org/about-suicide/suicide-statistics/ (10) Applied Suicide Intervention Skills Training: https://www. sprc.org/resources-programs/applied-suicide-interventionskills-training-asist (11) Joiner, Thomas. The interpersonal-psychological theory of suicidal behavior. American Psychological Association 2009. https://www.apa.org/science/about/psa/2009/06/sci-brief (12) Understanding Suicide: Fact Sheet. (2015). www.cdc.gov/ violenceprevention/pdf/suicide_factsheet-a.pdf.

(13) Andrew, Louise et. al. Physician Suicide. Drugs and Diseases. Aug 2018. https://emedicine.medscape.com/ article/806779-overview (14) Chyngm D et al. Suicide Rates After Discharge from Psychiatric Facilities. JAMA Psychiatry, 2017 Jul; 74(7), 694-702 (15) httos://zerosuicide.sprc.org/ (16) Dazzi, T. et. al. Does asking about suicide and related behaviors induce suicidal ideation? Psychol Med. 2014 Dec; 44(16):3361-3 www.ncbi.nlm.nih.gov/pubmed/24998511.

(17) Dvoskin, J. Suicide Prevention and Treatment: Helping Loved Ones in Mental Health Crisis US House of Representatives Hearing //docs.house.gov/meetings Sept 18, 2014.

(18) Miller, et. al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry.

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2017 Jun 1;74(6):563-570.

(19) Joint Commission Sentinel Event Alert, Issue 56: Detecting and treating suicidal ideation in all settings. https://www. jointcommission.org/assets/1/18/SEA_56_Suicide.pdf.

(20) Patient Health Questionnaire-9 (PHQ-9) developed by Spitzer, Williams, Kroenke. http://www.cqaimh.org/pdf/tool_ phq9.pdf.

(21) Kroenke K, et al. The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Medical Care 2003, (41) 1284-1294.

(22) Columbia Suicide Severity Rating Scale developed by Kelly Posner. http://cssrs.columbia.edu/ (23) SAFE-T https://www.integration.samhsa.gov/images/res/ SAFE_T.pdf.

(24) Muralidharan S and Fenton M. Containment strategies for people with serious mental illness. Cochrane Database of Systematic Reviews, July 19, 2006.

(25) Knesper, DJ. Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. AAS and SPRC, 2010.

(26) Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk.

Cognitive and Behavioral Practice, 19: 256–264.

(27) Stanley B, et al. Cognitive Behavior Therapy for Suicide Prevention (CBT-SP): Treatment model, feasibility and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, October 2009;48(10): 1005-1013. 57.

(28) Comtois KA, et al. Collaborative assessment and management of suicidality (CAMS): Feasibility trial for nextday appointment services. Depression and Anxiety, November 2011;28(11):963-972. 58.

(29) Linehan MM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, July 2006;63(7):757-66.

(30) Bryan CJ, Mintz JM, Clemans TA, Leeson B, Burch ST, Williams SR, et al. Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: a randomized clinical trial. J Affect Disord (2017) 212:64–72.10.1016/j. jad.2017.01.028.

(31) Safety Plan Brown and Stanley https:// suicidepreventionlifeline.org/wp-content/uploads/2016/08/ Brown_StanleySafetyPlanTemplate.pdf.

(32) Lethal Means discussion works: Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A.,…Hendin, H. (2005). “Suicide prevention strategies: A systematic review.”

Journal of the American Medical Association, 294(16), 20642074. doi:10.1001/jama.294.16.2064.

(33) Harvard T.H. Chan School of Public Health’s “Means Matter” https://www.hsph.harvard.edu/means-matter/ (34) Luxton DD, et al. Can post-discharge follow-up contacts prevent suicide and suicide behavior? A review of the evidence.

Crisis: The Journal of Crisis Intervention and Suicide Prevention, 2013;34,32-41.60.

(35) Berrouiguet S, et al: Post-acute crisis text messaging outreach for suicide prevention: A pilot study. Psychiatry Research, July 30, 2014;217(3):154-7.

(36) Physician and Medical Student Depression and Suicide Prevention. American Foundation for Suicide Prevention. https://afsp.org/our-work education/physician-medical-studentdepression-suicide-prevention/ (37) World Health Organization. Integrating mental health into primary care: a global perspective. Geneva: WHO. January 26,2012.

Scholarly Article

Disparities in Mental Disorders in the St. Louis Region Introduction ental disorders are fairly common conditions in the U.S. Indeed, recent estimates indicate that one in five adults and one in ten young people had some form of mental illness in 2014.1 Even more worrisome, intentional self-harm (i.e., suicide) was the sixth leading cause of death for children under 18 years of age and the third leading cause of death for those 18 to 24 years of age in St. Louis County.2 Moreover, mental disorders are associated with higher prevalence of substance use disorders and other chronic diseases and people with mental disorders live 25 years less than those with no mental disorders. But one important challenge with respect to mental health is that access to treatment is not widely available.3 For example, in 2017, less than 20% of adolescents (12 to 17 years) that had emotional and/or behavioral problems received treatment (counseling or drugs).1 It is also estimated that in 2017 between 30 and 60% of people diagnosed with mental illness did not receive treatment for their condition.4 Utilizing hospital admissions data and vital records, this report describes trends and disparities for mental disorders in the St. Louis region.

m

Emergency Department (ED) Visits and Hospitalizations among Children (<18 years) In recent years, utilization of emergency department (ED) due to mental disorders increased among children under the age of 18 in the St. Louis Region. Specifically, among this age group, the average rate of ED visit for mental disorders was 110.3 per 10,000 population from 2012 to 2016. Looking at St. Louis County and St. Louis City separately, the rate of ED utilization increased by 48% in the county and by 26% in the city from 2012 to 2016. Of note, wide disparities were observed by race/ethnicity in ED utilization. African American children were 1.6 times more likely to visit the ED compared to white children (150.4 vs. 89.2 visits per 10,000 population). By contrast, disparities in ED utilization were not observed when the data was stratified by neighborhood poverty levels (low: 0<10% below Federal Poverty Level (FPL); medium: 10<20% below FPL; high: 20<30% below FPL; and very high: >30% below FPL). This perhaps is a

function of the positive impact of wider availability of health insurance coverage among younger people. The most common admitting diagnosis among those who visited the ED was mood disorder.

Overall, there were an average of 1,809 mental health hospitalizations annually among children under 18 years of age in St. Louis County and 520 in St. Louis City. Both in the county and city, children 15 to 17 years of age had the highest rates of mental health hospitalizations. In this group, the rate of hospitalization increased 3% in the county and 8% in the city each year from 2010 to 2016.

Again, disparities were observed in hospitalization rates by race/ethnicity. Figure 1 (pg. 20) shows trend of hospitalization rate for St. Louis County and St. Louis City by race.

Emergency Department Visits and Hospitalizations among Adults (Ages 18 Years and Older) From 2012 to 2016, there were on average 26,740 ED visits due to mental disorders among adults in the St. Louis region (St. Louis County and St. Louis City). This represents ED visit rate of 175.0 per 10,000 in St. Louis County and 307.9 per 10,000 population in St. Louis City. In the St. Louis region, there were notable disparities in ED visits among adults by different groups. In particular, adults 18 to 24 years of age consistently had the highest rates compared to other age groups in St. Louis County while those 45 to 64 years of age had the highest ED visit rates in the city. Across the region, African Americans consistently had the highest rates compared to white residents: 283.0 per 10,000 population vs. 146.4 per 10,000 population in St. Louis County and 414.9 per 10,000 population vs. 231.6 per 10,000 population in St. Louis City.

Similarly, across the region, residents living in high neighborhood poverty level consistently had the highest rates of ED visits.

Overall, from 2010 to 2016, hospitalizations for mental disorders represented 8% of all hospitalizations in St. Louis County and 13% in the city. These translate to hospitalization rate of 131.8 per 10,000 population in the county and 235.7 per 10,000 population in the city. When broken down by neighborhood poverty level, overall, those

Nhial T. Tutlam, PhD, MPH

Echo Wang, MPH

Aleksandr Bukatko, MPH

Olivia Chapman, MPH

MO-AFP.ORG 19

living in high neighborhood poverty level had the highest hospitalization rates. Figure 2 below shows age-adjusted hospitalization rates for St. Louis County and St. Louis City. Notably, regardless of poverty strata, residents 65 years and older had lower hospitalization rates compared to other age groups and their rates were similar across the different poverty levels. This may be due to the fact that those in this age group have access to similar healthcare through the Medicare program.

During the same time frame, African Americans had 1.5 times the hospitalization rate of white residents in both the county and the city. Men were hospitalized at higher rates compared to women: 146.1 per 10,000 vs. 118.4 per 10,000 population in St. Louis County and 293.2 per 10,000 vs 180.2 per 10,000 population.

Emergency Department (ED) Visits due to Intentional Self-Harm and Suicide Mortality Intentional self-harm (i.e., suicide) is a major public health problem in the St. Louis region. From 2012 to 2016, there were a total of 8,905 ED visits following an episode of intentional-self harm. The overall rate of ED visits related to intentional-self harm was 14.2 per 10,000 population; the rate increased by 19% during this time frame. Indeed, using joint point regression analysis of trends, we assessed the annual percentage change in ED visit and it is apparent that from 2010 to 2016, the rates increased annually. Specifically, the age-adjusted ED visit rates increased 5.5% each year overall (yellow line in Figure 3). Similar increase was also observed across different racial/ethnic groups. In terms of Figure 1.

Age-adjusted hospitalization rates for mental disorders among children <18 years by race/ ethnicity, 2010â&#x20AC;&#x201C;2016.

Figure 2.

Average age-adjusted hospitalization rates for mental disorders for adults 18 years and older by neighborhood poverty levels, 2012â&#x20AC;&#x201C;2016.

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demographic distribution of those who visited the ED for intentional self-harm, more than one in five (22%) of these cases were children under 18 years of age. In the St. Louis region, a majority of ED visits due to intentional self-harm were female among all age groups. Importantly, among children under 18 years, 77% ED visits for intentional self-harm were female for both the county and city. Notably, for St. Louis region as whole, there were notable disparities by race in ED visits due to intentional self-harm. However, unlike other mental health conditions, when we look at the county or the city separately, there is essentially no difference in rates of ED visits for intentional self-harm by race.

However, when stratified by neighborhood poverty level, there is apparent increase in rates as the level of poverty increases, suggesting poverty level as a factor that needs to be examined closely. In terms of geographic distribution, as shown in Map 1, there are pockets of high rates, ranging from 20.8 to 301.4 per 10,000 population throughout the region.

Conclusions In the St. Louis region, there are notable disparities in both emergency department (ED) visits and hospitalizations due to mental disorders.

These disparities manifest along race/ethnicity lines, neighborhood poverty level and geographic location. We have also observed disparities for intentional self-harm but unlike other conditions, there was no difference in rates by race/ethnicity in the St. Louis region as a whole.

Figure 3. Average percent change of ED visit rates due to suicide attempts and/or intentional selfharm in the St. Louis Region, 2010 – 2016.

Map 1. Age-adjusted ED visits rates for intentional-self harm by census tracts, 2012 – 2016.

Authors Dr. Nhial T. Tutlam is the Chronic Disease Epidemiology Program manager in the Division of Health promotion and Public Health Research at Saint Louis County Department of Public Health. Dr. Tutlam is also the Project Director for Project RESTORE, a minority youth violence prevention project funded by the Office of Minority Health in the U.S. Department of Health and Human Services. Dr. Tutlam’s research interest include intergenerational impact of war trauma, chronic diseases, and maternal and child health. Dr. Tutlam is adjunct faculty at Lindenwood University.

Ms. Echo Wang is the mental health epidemiologist in the Division of Health promotion and Public Health Research at Saint Louis County Department of Public Health. Prior to coming to Saint Louis County Health Department, she worked as a biomedical informatics assistant at Washington University School of Medicine. Now, she primarily works on mental health outcomes tracking and evaluation in the St. Louis Region.

Mr. Aleksandr Bukatko is a biostatistician in the Division of Health promotion and Public Health Research at Saint Louis County Department of Public Health and an adjunct researcher at SLU School of Medicine.

Ms. Olivia Chapman is a chronic disease epidemiologist with the Division of Health Promotion and Public Health Research at Saint Louis Department of Public Health. She is a MPH graduate from Saint Louis University.

References 1. Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/ NSDUHFFR2017.pdf 2. Kret, JE, Tutlam, NT, Dalidowitz Dame, L, Wang, E. Leading Causes of Death Profile, St. Louis County Missouri. Chronic Disease Epidemiology (CDE) program profile, no 6. St. Louis County, MO: Department of Public Health. September 2017.

3. National Association of State Mental Health Program Directors Council. (2006). Morbidity and Mortality in People with Serious Mental Illness. Alexandria, VA: Parks, J., et al. Retrieved January 16, 2015 from http://www.namiut.org/images/stories/october_2006_morbidity_and_mortality_pub.pdf 4. Wang, PS et al. "Failure and Delay in Initial Treatment Contact After First Onset of Mental Disorders in the National Comorbidity Survey Replication," Archives of General Psychiatry (June 2005): Vol. 62, No. 6, pp. 603–13.

Non-Member Opinion

Stopping Burnout at the Source: Delegating the Administrative Burden was drowning in a sea of administrative across the United States. The TCM Model reflects requirements. With the advent of the a handful of basic insights but, like individual steps electronic health record (EHR) at my health in a dance, putting them all together in a cohesive, system, I moved much more slowly through organic sequence takes good coaching and patient visits and spent much of my time intentional practice. To be clear, it is not a set of staring at the screen rather than making eye tips and techniques to be selected a la carte based contact with my patients. I poured more and more on personal preference. of my days (and my evenings) into tasks that did The transformation starts with a major shift not require years of medical school and residency in mentality for the physician. Though medical training. Like all too many other family physicians, I schools rarely include the management training was burning out. coursework included in an MBA program, providers My long-time nurse felt similarly worn out and must embrace the reality that they manage a when she turned in her resignation, it was the last team. Their role can and should be less like the straw—I knew I needed to figure out a better way star player that needs the ball in their hands all the of practicing medicine. time and more like the team captain that raises the What I wanted was an experience more like performance of the entire team through coaching a surgeon, who walks into the operating room and leadership on and off the court. with the patient prepared, the equipment ready, In the TCM Model, the clinical staff (registered and the nurses available. That vision inspired me nurses, medical assistants, etc.) take on a role to tinker, experiment, and innovate to create a called the Team Care AssistantTM (TCA). They comprehensive primary care workflow that would execute six discrete steps in the patient visit. allow me to focus just on the tasks that required Crucially, the physician is only present for two my MD designation. of them. Much of the administrative work is Equipping, empowering, and expanding my performed at the beginning and the end of the clinical support staff not only freed me up from visit, and is performed by the TCA rather than the administrative tasks that I should have delegated physician. When the physician is present, the TCA years earlier, it also allowed me to improve summarizes the preliminary medical information care and increase patient access. I was enjoying that has already been collected, in much of the medicine again and was going home at night same way that a medical student presents the with my charts 100% current. My patients were patient’s case to the attending physician. Then delighted to find that they could now make samethe TCA scribes the very concise examination by day appointments for acute conditions rather than the physician, freeing up the physician to hone in seeing a stranger at an urgent care center. System on the diagnosis and prescription without even leadership at Riverside Health System in Newport touching the keyboard.

News, VA, was delighted to see my financial profile VISIT FLOW OF THE TCM MODEL flip from losing six figures per year to the most Patient + TCA + Provider Patient + TCA Patient + TCA productive practice in the network.

In the ensuing years, the Team Care Medicine 5 6 2 1 3 4 (TCM) Model has been endorsed by the American Medical Association, the American Board of Record the Execute Close Set Visit Collect Deliver Provider’s Exam Ordering Visit Expectations Preliminary Presentation Internal Medicine, the American Academy of & Treatment Plan Data to Provider Family Physicians, and other healthcare leaders 6 TCA Skills

i Peter Anderson, MD

James Anderson, MD

www.teamcaremedicine.com

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"

I was enjoying medicine again and was going home at night with my charts 100% current."

Because they operate extensively without the physician in the room, each TCA offers dramatically more leverage to the physician’s time than a scribe. Indeed, a high functioning TCM physician can be supported by up to four TCAs at the same time, while an individual physician never needs more than one scribe. A simple workflow with two TCAs is illustrated below.

PROVIDER HOURLY WORK FLOW Patient #1

TCA #1 Provider

0

Patient #3

.........................................................................................

60

Minutes

TCA #2 Patient #2

Patient #4

www.teamcaremedicine.com

In recent years, the Team Care Medicine Model has been adopted by a range of practices from coast to coast, including small federally qualified health centers and large integrated delivery networks. Physicians have learned to coach, to lead, and to delegate in the exam room. They’re reporting restored joy in medicine as they engage the patient rather than the computer and go home on time with all their charts current. With improved clinic access, patients are delighted

to get same day acute appointments with their own physician rather than an urgent care center. Executives are pleased by a strong ROI as the increase in visit volumes easily covers the conversion costs, not to mention the improved morale and retention of the physicians. This is just the beginning and I’m delighted that relief from administrative burden is beginning to restore primary care nationwide. Visit www. teamcaremedicine.com for more information.

Dr. Peter Anderson, practiced family medicine in Virginia for 35 years. He retired from practice in 2012 to establish Team Care Medicine, LLC, and devote his full-time attention to transform health care delivery around a familiar physician. Anderson has trained hundreds of physicians around the U.S. in his Team Care Medicine ModelTM, a widely acclaimed and accepted practice model that epitomizes highest and best use of clinical staff. He has authored three books and has often been a keynote speaker at national health conferences.

Dr. James Anderson serves as CMO at Team Care Medicine, helping doctors find greater joy by lightening the load of EHR documentation, freeing them to focus on relationships with patients and medical decision-making. Dr. Anderson is a primary care physician whose clinical career spans more than 40 years. He is board-certified in both family medicine and emergency medicine.

Anderson has received multiple awards as a family practice educator and has helped train over 200 primary care residents.

MO-AFP.ORG 23

Non-Member Opinion

An Argument for Integrated Behavioral Health

magine you have a patient sitting in front of you, tearful and distraught. Describing feeling depressed and hopeless. Not being able to sleep or eat. Not feeling motivated to get out of bed, go to work, or even spend time with their family. This experience has made it hard for the patient to manage their illness or take their prescribed medications.

What do you do? Do you provide the patient with care for their obvious depressive episode? Do you refer them to therapy? To psychiatry? Do you validate the patient then try to shift focus to what they are coming in to see you for? Do you ignore the symptoms completely?

These statistics may be familiar to some, and surprising to others. One in every five U.S. adults experiences a mental illness at any given time.

This equates to 43.8 million American adults each year. It has been estimated that 46% of U.S. adults will experience a mental illness or substance use disorder in their lifetime. Of those individuals, approximately 67% do not receive mental health treatment.1 This may be related to mental health stigma, lack of insurance or financial resources, or limited access to specialty mental health including therapy and psychiatric medication management.

The Missouri Department of Mental Health2 estimated that 828,000 Missouri adults experience

i Carlie Nikel, PsyD Dr. Carlie Nikel is a licensed psychologist who provides integrated behavioral health services at Truman Medical Center in Kansas City, Missouri.

She is also the Associate Program Director and Director of Behavioral Science for the University of Missouri- Kansas City Family Medicine Residency Program.

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MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019

any mental illness in a given year. Also, Missouri ranks 40th in access to mental health care.

With the high prevalence rate of mental illness, limited access to specialty mental health care, and high likelihood of treatment occurring in primary care, how can we insure that proper care is available for our patients? The answer may lie in the collaboration of medical and mental health care.

Integrated Behavioral Health Integrated Behavioral Health (IBH) has many definitions and variations in delivery. In 2013, Peek described IBH as the following:3 The care that results from a practice team of primary care and Behavioral Health Consultants (BHC), working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.

This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. (p.2) The model of IBH can be delivered in six levels of care ranging from minimal coordination of care with emphasis on communication, to co-located

care with emphasis on close proximity of team members, to full collaboration between team members with emphasis on integration into every aspect of practice. Each level of care provides benefit to the patient and team, with level six full collaboration having the greatest impact on overall care.

The BHC mentioned by Peek (2013) is typically a Licensed Psychologist or a Licensed Clinical Social Worker (LCSW) who works as a member of the care team. The BHC addresses not only the mental health concerns often seen in medical settings but also health behaviors and physical conditions that are impacted by mental health issues. These may include treatment adherence, behavior change plan implementation, and adjustment to a chronic medical condition.

This lowered stress may be attributed to reduced time spent with patients focusing on nonmedical topics.

Lastly, IBH helps to reduce overall healthcare costs. CDC (2014) indicated that 75% of healthcare costs are due to chronic diseases, which can be influenced by lifestyle and behavioral changes.1 These changes can be the focus of treatment with a BHC. Additionally, the unnecessary use of medical service lines such as the emergency department has been reduced with the addition of IBH.

"

Goals of IBH Although Peek (2013) described the collaborative care provided in primary care, the themes and goals outlined can be generalized to the care provided within various specialties such as oncology, sleep, and pain management, just to name a few.

The goals of IBH are simple: increase access to care, improve patient quality of life, improve satisfaction for patient and provider, and improve cost management and overall healthcare spending.

To better understand how IBH can meet these goals, letâ&#x20AC;&#x2122;s break each one down.

First, IBH increases access to care. As mentioned earlier, most individuals do not receive mental health treatment, and for the patients that do receive care, over 20% of them receive their treatment solely from primary care.1 Even when a provider refers a patient to outside specialty mental health, only 10% of those patients follow through on the referral.3 When there is a BHC integrated into that clinic, 90% of patients needing treatment for their mental illness receive it.5 Since most adults visit a primary care office within a course of a year, integrating a behavioral health specialist into that office can ensure that patient needs are met.

Second, IBH improves quality of life for patients.

When a patient can have both physical health and mental health care needs met in one place, by one collaborative team, quality measures tend to improve. Reported symptoms of depression reduce in severity after one visit with a BHC.6 Next, IBH improves satisfaction for both the patient and providers involved in care. Patients report greater satisfaction in care received, which may be associated with feeling heard and understood by their providers.

When provider satisfaction was examined, nearly 94% of physicians thought IBH improves patient care and 90% believed IBH lowers physician stress.4

When provider satisfaction was examined, nearly 94% of physicians thought IBH improves patient care and 90% believed IBH lowers physician stress."

Day to Day Practice The daily practice of a BHC can vary dependent on the level of integration and the clinic workflow.

This is an example of a typical workflow of a BHC in a level six fully collaborative program.

The BHC often sits with the medical staff and is readily available for an on-demand consult.

When the physician has identified a patient that would benefit from the BHC services, a brief consultation is provided to the BHC, who then sees the patient in real time. The interaction between the patient and BHC focuses on information gathering, psychoeducation, goal setting, brief therapeutic techniques, and treatment planning.

The interaction is brief and solution focused, and typically lasts less than twenty minutes. The BHC documents the encounter in the same EMR as the physician. The BHC then collaborates with the referring provider on the care provided and team based decisions can be made regarding treatment.

Letâ&#x20AC;&#x2122;s revisit the patient described in the beginning. If a patient described depressive MO-AFP.ORG 25

symptoms and mentioned how it was impacting their ability to manage their health in a clinic with IBH, the physician could ensure that the patient’s mental and behavioral health needs are addressed. In a level six fully collaborative IBH program, the physician could immediately consult the BHC in person and the patient would be seen before their medical visit was concluded. This would allow for collaborative decision making to be done with the patient, physician, and BHC. The BHC could continue to meet with the patient at follow-up medical appointments, make stand alone BHC appointments, or coordinate the transfer of care to specialty mental health if needed.

There are several great examples of IBH in Missouri. I can personally speak to the robust program located at Truman Medical Centers (TMC) in Kansas City, Missouri. Currently, within the TMC system, there are eight Psychologists integrated into several primary care and specialty clinics.

Within those clinics, there is a range of integrated care provided, from co-located to fully collaborative between medical and behavioral health providers. The TMC system is a teaching hospital affiliated with the University of Missouri – Kansas City, which provides the opportunity for education and interaction with IBH early in medical and psychological education. The TMC IBH program allows for medical students, resident physicians, fellows, and doctoral psychology students to have firsthand experience of the impact of IBH on patient care. Due to the success of the program, IBH is actively expanding at TMC to better suit the needs of the patient population it serves.

In summary, IBH is a model of care that emphasizes increasing access to mental health care, meeting patient needs, decreasing healthcare costs, and focusing on care team wellbeing. IBH is a means to provide treatment for not only mental illness but also to assist in building patient self-management skills to better care for chronic diseases or implement behavioral change. Although the integrated of behavioral health into medicine can vary, the benefits are palpable. I challenge each of you to think of your patient population and assess the utility of IBH in your practice. How can IBH help you meet your patients’ mental and physical health needs?

References 1. Center for Disease Control and Prevention. Percentage of mental healthrelated primary care office visits, by age group - national ambulatory medical care survey, United States, 2010. Morbidity and Mortality Weekly Report.

2014;63(47);1118.

2. Missouri Department of Mental Health. Status report on Missouri’s substance use and mental health. Status Report. 2018; 24; A11.

3. Peek CJ, the National Integration Academy Council. Lexicon for behavioral health and primary care integration: Concepts and definitions developed by expert consensus. AHRQ Publication. Rockville, (MD): Agency for Healthcare Research and Quality, 2013.

4. Miller-Matero LR, Dykuis KE, Albujoq K, Martens K, Fuller BS, Robinson V, Willens DE. Benefits of integrated behavioral health services: The physician perspective. Families, Systems, & Health. 2016; 34(1), 51–55.

5. Cummings NA, O’Donohue WT, Cummings, JL. The financial dimension of integrated behavioral/primary care. J Clinical Psychology in Medical Settings.

2009; DOI 10.1007/s10880-008-9139-2 6. Balasubramanian BA, Cohen DJ, Jetelina KK2 Dickinson LM, Davis M, Gunn R, Gowen K, deGruy FV, Miller BF, and Green LA. Outcomes of integrated behavioral health with primary care. J Am Board Fam Med. 2017;30(2):130139. doi: 10.3122/jabfm.2017.02.160234

Member Opinion

Teens, Depression, Anxiety, Suicide, and Social Media nstagram, Snapchat, Facebook, Twitter, Pinterest, YouTube, and Tik Tok are social media applications and access points to adolescents and teens. In the past, children went outside from dawn until dusk playing until the streetlights came on or their parents called them in for dinner. Fast forward this setting to today. Our youth are faced with access to the world at their fingertips on cellphone and tablet screens. Unfortunately, this means the world also has 24-hour access to them. No longer will a bad hair day or a school prank be a distant memory.

Social media ensures these vulnerable moments are permanent and available to the world. Home is no longer a safe place or shelter away from the world. The awkwardness of growing up is shared with the world. One bad choice, or rather one bad outfit or haircut, can change the course of a life.

Adolescent and teen brains are still developing.

The frontal lobe is not mature until approximately age 25. Impulse control is limited and the ability to process and consider actions and reactions is also limited. Unfortunately, the high speed of social media and slow adolescent brains is a bad combination. Adolescents and teens also lack the ability to see beyond the immediacy of their current situation in place and time. The future is here and now. This can cause adolescents to feel isolated and alone. Their social interactions are often only through a screen, which worsens the isolation.

Adults age 25 and over remember childhood as a world without the influence of social media.

Children now have exposure to social media from birth. Unfortunately, for adolescents and teens today, they are more susceptible to depression and have an increased risk of suicide due to the influences of social media use. This was highlighted in a recent article in the Journal of the American Medical Association Psychiatry on September 11, 2019.1 Regular use of social media occurs between 12 -15 years old. Internalization of the negative effects of social media occurs at 14-17 years old. Spending three to six hours on social media daily leads to a 60% higher likelihood of experiencing depression and anxiety than those

i

who didn’t use social media. Those who spent more than six hours a day on social media were at 78% increased risk. The social media group also noted poor sleep quality and increased risk of cyberbullies.1

"

Social Media ensures these vulnerable moments are permanent and available to the world."

Family physicians can make a difference. We will not likely change social media exposure for teens and adolescents or their use frequencies or patterns. However, we can help parents and teens that we see in our offices every day. Educate parents on the signs of depression, anxiety, and suicide. Often, teens will display different signs than adults. Parents need to keep open lines of communication with their children. Adolescents need to have adults in their life that will mentor them such as a pastor at church, school counselor, teacher, coach, or an aunt or uncle. Sometimes teens don’t want to talk to their parent, but they will talk to a trusted adult. Parents also need to know what social media and apps are on their teen’s cellphone. Parents need to know how to use the apps and have access to them. Active use of the PHQ-2 and PHQ- 9 help as screening tools and conversation starters. Asking questions regarding adolescent and teens about hobbies or what they enjoy doing most; as well as their feelings about school and their activities can also be insightful. Well-child exams or sports physicals are perfect opportunities to open conversations with patients and their parents. Training office staff and nurses on recognizing signs of depression, anxiety, and suicide will also help and may save a life.

Kathleen Eubanks-Meng, DO Dr. Kathleen EubanksMeng is a board certified family medicine physician at Summit Family and Sports Medicine, in Lee’s Summit, Missouri. She is a past president of the Missouri Academy of Family Physicians, and has practiced in the Kansas City area for the last seventeen years.

Resources and References The National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or the Crisis Text Line by testing “START” to 741-741.

If you believe there was an over dose, National Poison Hotline 1-800-222-1222.

The AAFP also has resources on Teen Suicide Prevention at https://www.aafp.org/patientcare/public-health/teen-suicide. html 1. Riehm, K. E., Feder, K. A., Tormohlen, K. N., Crum, R. M., Young, A. S., Green, K. M., …

Mojtabai, R. (2019). Associations Between Time Spent Using Social Media and Internalizing and Externalizing Problems Among US Youth. JAMA Psychiatry, 1.

MO-AFP.ORG 27

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MEMBERS IN THE NEWS Pullam Receives "Great Catch" Award In June, resident physician, Dr. Kris Pullam, was awarded Mercy Hospital-St. Louis "Great Catch" award by the Patient Safety Committee. Dr. Pullam identified and corrected an error in opioid dosing conversion before the medication was administered to the patient.

NEWS TO SHARE?

E-mail photos and news you would like to see published in the Missouri Family Physician to office@mo-afp.org for review.

Mourad, Salah, awarded Crescent Peace Society Community Service Award Dr. Wael Mourad and his wife, Dr. Sally Salah, were awarded the Crescent Peace Society Community Service Award on behalf of The Medina Clinic, a 501(c)(3) not for profit charitable volunteer based medical clinic dedicated providing quality primary care services in the greater Kansas City metro region and beyond.

Mourad and Salah co-founded The Medina Clinic in 2009.

2019 Externship Experiences Co-sponsored by the American Academy of Family Physicians Foundation & the Family Health Foundation of Missouri. The AAFP and FHFM have partnered to offer four-week summer externships to Missouri medical students interested in pursuing a career in Family Medicine. This years award recipients were Emily Shank, Rocky Leng and Dan Vy Diem Tran. Below are their experiences.

Emily Shank I was fortunate to be selected for the summer externship program through the American Academy of Family Physicians and the Family Health Foundation of Missouri. I am grateful I had this opportunity to spend my summer learning from the excellent faculty, residents, and staff at the Mercy Family Medicine Residency Program. As my mentor, Dr. Sarah Cole offered insight into how to provide quality patient care as a family doctor and her enthusiasm for family medicine was inspiring. Throughout the four weeks, I experienced the scope of family practice from outpatient clinic to inpatient rounds and newborns in the nursery to geriatric patients at St. Agnes Home. After completing my first year of medical school, it was beneficial to work in an environment that emphasized evaluating a patient as a whole. Every patients’ health challenges become a team effort to work through and overcome. During the clinical experience, I interviewed patients, performed physical exams and osteopathic structural exams, and observed procedures.

I participated in grand rounds, sports medicine didactics, and the OMT clinic for first year residents, performed a community health needs assessment of the St. Louis area, and attended the MAFP Show Me Family Medicine conference. In addition, I expanded my knowledge through online learning about school-based health care. Each patient encounter contributed to my education and growth as a student doctor, and I will take the skills I learned throughout the summer externship into my future career. I am looking forward to recommending this program to other Missouri medical students.

Rocky Leng In the past four weeks as an MAFP summer extern, I bore witness to the humanity inherent in medicine. It was evident in the patient questions. From the relatively common (“When will my pain go away?”) to the profound (“Will I forget who I am?”), questions such as these unveiled how vulnerable patients are when they see physicians. It was humanizing. What a subtle yet powerful appeal

to humanity it is to ask one’s doctor what a life with diabetes is like or what forgetting one’s identity means. I struggled, however, in finding an answer to these questions. A word-for-word reading from the relevant UpToDate article is not enough while a deeply personal, non-medical response does not quite fit into the white coat either. These questions compel an answer not just informed by medical knowledge but a deep familiarity of the human condition. When an appeal to humanity is made, the response must be likewise humane. This requires physicians to be authentic, not just professionally but as human beings humbly aware of their own mortal coil.

I admit, this conclusion may seem like a platitude. Of course, we should be patient centered. Of course, we should see patients as human beings. Of course, we should know ourselves and the mortal and moral implications we have on others. Of course. The rub is this: how do we do it every day? To bear the responsibility of human life, the practice of medicine necessitates an authenticity to self, not just for a given interaction on a given day but every day and all days. Can I be the human being I want to be in Family and Community Medicine – even against the backdrop of burnout, burdensome EHRs, limited time with patients, and other possible realities? My four weeks as an MAFP summer extern aimed to answer this question.

My time, however, made me realize I asked the wrong question.

Foremost, the external factors I was concerned about, such as heavy EHR burden and limited patient time, did not seem to be a huge barrier to patient-physician relationships. My externship coincided with the last weeks of some of the third-year residents. I was present when they told their patients they would be moving on to other endeavors. As I followed them into patient rooms, smiles and hugs often opened the interaction while attempts to not sound too sad closed them. Their daily rhythm beat efficiently and ever forward. The EHR was subservient in the patient room, a tool for both note-taking and documentation when it was needed. Between patients, a chorus of keys filled the resident room. Pausing to discuss happiness, expectations, and needs with a medical student seemed to have no effect on momentum. Yet, as the hours of my externship experience turned to days and the days turned to weeks, I found my razor focus waning from cultivating meaning to other daily matters – studying for next year’s exams, being with family, and enjoying my last summer break. I wrestled with myself on this. I applied for this externship specifically to explore meaning, living, and family medicine. I had a duty to myself, my current patients, and my future patients to keep my focus sharpened. Thoughts like these can wait, right? Probably, but maybe that is not for the best.

Continued on page 31 MO-AFP.ORG 29

We Want to Recognize You We all have exemplary family physicians whom work hard for their patients and profession. In the past, the Missouri Academy of Family Physicians recognized the Missouri Family Physician of the Year at our annual meeting. We want to do more to recognize your efforts for improving Missouri health care and have added four new awards to recognize family physicians who are in the forefront of this effort.

Resident Stipend Award

This award is to help Missouri residents understand the complex negotiation process as they transition to a full-time Missouri family physician. The recipient should exhibit exemplary patient care, demonstrate leadership, display a commitment to the community, contribute to scholarly activity and is dedicated to the specialty of family medicine. This financial award (up to $500) will be presented to one resident per Missouri family medicine residency program per year to have their Missouri employment contract reviewed by an attorney of their choosing and/or financial planning consultation. The recipient is selected by the Missouri family medicine residency program during the residentâ&#x20AC;&#x2122;s 2nd or 3rd year of residency.

In addition, the recipient will receive one free MAFP conference registration for the Show Me Family Medicine Conference, valued at $275 (early bird rate), within the first three years after completing residency.

The deadline for nominations is March 31.

Exemplary Teaching Award

Acknowledges MAFP members who deserve recognition of exemplary teaching skills, as well as individuals who have implemented outstanding educational programs and/or developed innovative teaching models. The recipient must be in active practice, spend at least 50 percent of his/her time in the academic setting, be a MAFP member in good standing, be board certified in family medicine and/or an AAFP Fellow, and be in academics at least ten years since completing residency training. The deadline for nominations is February 3.

Outstanding Resident of the Year Award

Presented to a graduating Missouri resident who exhibits exemplary patient care, demonstrates leadership, displays a commitment to the community, contributes to scholarly activity and is dedicated to the specialty of family medicine. The nominee for this award must be a current resident member of MAFP

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MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019

and be graduating from a family medicine residency program in Missouri. MAFP members, family medicine residency faculty, or other members of a family medicine residency administrative staff may submit nominations for the award. The deadline for nominations is February 3.

Distinguished Service Award

Recognizes members, nonmembers, and entities for long-time dedication to advancing, contributing, and supporting to the MAFP and the specialty of family medicine - rather than through a single, significant contribution and effective leadership in furthering the development of family medicine. This award is not limited to members only. Nominations must include a letter of recommendation and should include a brief summary of the entity or personâ&#x20AC;&#x2122;s accomplishments and why the award is deserved for distinguished and dedicated efforts furthering the specialty of family medicine. Nominations may be received from members or MAFP staff. The deadline for nominations is February 3.

Family Physician of the Year Award

This award continues the tradition of recognizing a member who provides his/her patients with compassionate, comprehensive and caring family medicine on a continuing basis; is directly and effectively involved in community affairs and activities that enhance the quality of his/her community; provides a credible role model, both professionally and personally, to his/her community, to other health professionals, and to residents and medical students; effectively represents MAFP and the specialty of family medicine by presenting a good public image; and exemplifies the family physicianâ&#x20AC;&#x2122;s leadership role in improving the health of our state. The recipient must be in active practice, spend at least 50% of his/her time in direct patient care of residents of Missouri, be an MAFP member in good standing, be board certified in family medicine and/or an AAFP Fellow, and be in practice in Missouri at least 10 years since completing residency training. Nominations may be received from the public, members, or MAFP staff.

The deadline for nominations is February 3.

All nominations must be submitted online from the MAFP website at www.mo-afp.org/members/ member-recognition/ *MAFP reserves the right to use discretion whether or not to award a nominee annually.

2019 Externship Experiences continued...

As routine sets in, perhaps it is normal to look towards other areas of life outside of medicine. Perhaps this is that work-life balance I keep hearing about.

Upon reflection, I realized it is. Seeing this issue as work-life balance instead of a deficit of character shifted the narrative of my experience in medicine. This shift was grounded upon the first-year challenges of medical school. In that year, I struggled academically for the first time. In response, my life as a human being came second to academic fervor, and I burned out in the process. I worked my whole life to be here, I thought. Surely, I could suffer through this. As it turns out, I could not. As I struggled and found my cadence again in medical school, I confronted my own humanity – vulnerable and open like the patients I would see in the externship. I am not perfect. I am not a martyr, nor do I want to be. A focus on being human, on work-life balance, became my primary preoccupation; I forgave myself for my imperfections. Thinking of this journey contextualized my work-life balance issue during the externship and for the rest of my career. I do not need to be perfection every day and all days to bear the moral/mortal questions of patients. That perfection is an asymptote to perpetually strive for and always fall short of. Otherwise, I would not be human. Thus, the right question to ask is this: can I be a complete human being – imperfect, vulnerable, yet always striving for improvement – in Family and Community Medicine?

Yes. This answer dawned with the consistency and strength of the rising sun. Passion for life, inside and outside the clinic, illuminated all of my externship experiences. Participation in POEMs groups, projects on vaccine hesitation, conversations over concerns of new marijuana policy, and sharing of literature over the state/future of primary care showed me how conducive Family Medicine is to being engaged in medicine and selfenrichment. Conversations of family, hobbies, books recently read, and staff social events showed me the work-life balance I desired in the future. The wholeness of the human experience was evident in all these activities – joy, worry, contentment, frustration – and the pursuit of a life well lived never flickered or diminished. To answer the mortal questions of patients, I thought I needed to rise above human adversity every day and in all days. In reality, the perfect answer does not exist, but the authenticity needed to begin to find answers together can

be gained from living a whole life, striving for – and sometimes failing in – the betterment of ourselves professionally and personally. In sharing the complexity of the human experience with patients every day and in all days, perhaps together we might find some answers.

Dan Vy Diem Tran This summer, I had an opportunity to experience a full-spectrum family medicine with an underserved population in the city of St. Louis. I started out shadowing a resident and learned how to properly do an H&P. While the resident works on the assessment and plan, she would explain to me her thought process and allow me to ask questions. This made the shadowing experience very interactive and aided my understanding on the topics in which I was not very familiar with. Much to my surprise, on the second day I got to see the patients by myself. It felt wonderful to take the knowledge, everything that I have learned in the pre-clinical years, and tried to figure out how to make it useful and practical for patients. I was simply amazed at the level of trust and openness the patients provided to me. Listening to their concerns and problems, I realized how a person health is greatly affected by his or her environment and that taking into account individuals’ racial, ethnic, cultural, and socioeconomic backgrounds is a crucial element in providing quality care.

Since the class size at SLU Family Medicine Residency is small, I got to rotate with most of the residents and all of them were responsive and interested in teaching and education. For example, once I got to familiarize myself with patient care, I was often asked, “What do you want to do with this patient?”. This forced me to think through things. Though I was not always right, they would give me an opportunity to look up the answer, or even better, they would teach me something. What is more, the residents spent their time to run through the oral presentation with me before I went to present the case to the attending physicians. Being actively involved in the process of taking care of patients and having a safe environment to learn were the two best parts of my externship experience.

Spending four weeks at SLU confirms my interest in family medicine. I think that I am fortunate to be given the opportunity to make this my life’s work. In my opinion, family medicine is the best way to be a doctor and be useful to the greatest number of people.

IT’S NOT A JOB, IT’S A WAY OF LIFE. CoxHealth opportunities Recruiting BC family medicine physicians to practice in outpatient clinics: • Marshfield, Missouri – new facility • Springfield, Missouri • Lamar, Missouri • Harrison, Arkansas • Branson, Missouri • Monett, Missouri - hospitalist Opportunities are also available in addiction medicine and pain medicine.

10%

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MILES OF TRAILS

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DAYS OF SUNSHINE

1-800-869-4201 | paula.johnson@coxhealth.com MO-AFP.ORG 31

Residents and Students Gat her for Nat ional Conference T his year’s National Conference for Family Medicine Residents and Students in July gathered over 1,900 students and 1,300 residents in Kansas City, of which 66 students and seven residents were from Missouri. This conference focused on “exploring more” and was an opportunity for leadership development, education, social and networking events, and visiting an Expo Hall. Missouri Street was again in a prime location in the Expo Hall to attract medical students to the Missouri residency programs, along with physician recruiters from Missouri hospital systems.

One of the 50 posters on display during the conference was from Missouri student, Morgan Dresvyannikov, University of Missouri-Kansas City, on her innovative program, Medical Explorers, aka, MedEx. This program is a curriculum that includes hands-on workshops to educate elementary school students about careers in healthcare, including family medicine. Morgan’s program was highlighted in the last issue of the Missouri Family Physician. In addition, the University of MissouriColumbia, and University of Missouri-Kansas City FMIG programs were recognized as “Programs of Excellence.”

Missouri’s delegates attending the conference were Christine Khong, MD, Resident, Research Family Medicine Residency, and Megan Reidy, Student, ATSU Medical School. Megan shared, “Serving as the student delegate at the AAFP National Conference was one of the most enriching experiences I have had during my time in medical school. The opportunity to learn about the AAFP and how it addresses important issues is something that I will continue to benefit from long into my career as a physician. During my three days in Kansas City, I received excellent hands-on leader training, met current and future AAFP leaders, and participated in the discussion of issues important to education and future practice. This experience was a big step toward becoming the leader I

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MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019

hope to be as a resident and beyond. I truly look forward to all future involvement with both the MAFP and AAFP as I become a family physician.”

During the three-day conference, family medicine residents and students elected their leadership to the AAFP board of directors and developed resolutions on physician wellness and additional training. Resolutions adopted addressed depression in students and residents, time off between shifts, and to update the member value statement to include mental and physical health of members. Students called for information on health care systems, economics and financing in educational materials, issues on social determinants of health, measures on the evaluation of osteopathic and allopathic residency applications, and a preferred gender pronoun.

Residents passed resolutions for AAFP to advocate for methadone maintenance treatment within primary care clinics without a separate federal license, a resolution addressing the closure of family medicine residency programs and hospital closures, and other resolutions focused on immigrant health. More information is available on the AAFP website.

Missouri delegates attended the annual reception and had an opportunity to network with each other, as well as elect their alternate board members on the MAFP board. Noah Brown, University of Missouri Kansas City was elected the alternate student board member, and John Heafner, MD, Saint Louis University, will serve as the alternate resident board director. Dr. Heafner previously served as the student director. Past alternate directors will move to the director positions: Morgan Dresvyannikov, University of Missouri-Kansas City, will move to the student director position; and Misty Todd, MD, University of Missouri Columbia, will move to the resident director position. Congratulations to all for your commitment, dedication and leadership to future family physicians.

2019-2020 COX FAMILY MEDICINE RESIDENCY AMILY 2019-2020 EDICINE ESIDENCY

COX F

M

R

Third-Year Resident Physicians

Kyle A. Gillett, MD

Second-Year Resident Physicians

Christopher A. Odehnal, MD

Lauren J. Branham, DO, MBA Chief Resident

Evan A. Branscum, MD

Trevor J. Conner, DO Chief Resident

Joshua W. Gaede, MD

Brian D. Kennedy, MD

Kelsey L. Keoppel, DO

Kayla B. Matzek-Kittle, MD

Cody S. Rogers, MD

Joseph W. Barnard, DO

Gabriela P. Cox, DO, MS

Steven A. James, MD

Karissa A. Merritt, DO

Bjai A. Rice, DO

M.H. Melany Su, MD

Caleb K. Tague, MD, MPH

Theodros M. Zemanuel, DO

Jacob A. Bolt, MD

Rachel M. M. Brown, DO

Margaret E. Givens, MD

J. Edward Hansen, DO

Shelby L. Laughlin, MD

Mario D. Martinez, MD, PhD

Kristen R. Snyder-Hernandez, MD

Rachel M. Watson, DO

First-Year Resident Physicians

Victoria R. Jackson, DO

MO-AFP.ORG 33

DEPARTMENT OF FAMILY & COMMUNITY MEDICINE DEPARTMENT OF FAMILY & COMMUNITY UNIVERSITY OF MISSOURI - COLUMBIA MEDICINE UNIVERSITY OF MISSOURI | SCHOOL OF MEDICINE 2019-2020 2019-2020 HOUSE STAFF Chief Residents

Joshua Bacon, MD Fulton

Tyler Gouge, MD Fayette

Misty Todd, MD Fulton

Carl Tunink, MD Fulton

Third-Year Residents

Justin Chang, MD SP-Blue

Jonathan Hoskins, MD Fayette

Eric Kadlec, MD Fulton

Laquita Brown, MD SP-Blue

Miles Crowley, MD SP-Blue

Kyle Hadden, MD Fayette

Ethan Jaeger, DO SP-Blue

Zachary Barker, DO Fulton

Reiana Mahan, MD SP-Blue

Lisa Camilleri, MD SP-Blue

MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019

Second-Year Residents

Alyssa Emery, MD Fulton

Savannah Ericksen, DO Family Health Center

Alexander Finck MD Fayette

Rose Glastetter, DO Fulton

Colin McDonald, MD Family Health Center

Matthew Roehrs, DO SP-Blue

Jessica Snyder, MD Fulton

Zachary Treat, MD Fulton

Brook “Beau” Bounous, DO Fayette

Oluwatoke “Toke” Omiwade, DO SP-Blue

Maggie Brennan Family Health Center

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Lisa Wadowski, MD SP-Blue

Mary Murphy, MD SP-Blue

First-Year Residents

Diane Bussan, MD SP-Blue

Ryan Muehling, MD Fayette

Stephanie Espinoza, MD Family Health Center

Gabriel Eljdid, DO SP-Blue

Oyenmwen Edo-Ohonba, MD Family Health Center

Marc Propst, MD Fulton

Humza Quadri, MD SP-Blue

Integrated Residents

Dalton Lohsandt Fayette

Eva “Veronika” Kiss, MD Family Health Center

Jason Fultz, DO SP-Blue

Jacob Seevers, DO Fulton

Nicole Seddon SP-Blue

McKenzie Veldhuizen, MD Fayette

Cynthia “Brea” Lombardo, MD SP-Blue

Stephanie Zafiris, MD Fulton

MercyMERCY Family Medicine FAMILY MEDICINE RESIDENCY 2019-2020 Resident Roster 2020-2022

First-Year Resident Physicians | Class of 2022

Chelsea Daniels, MD Advisor: PHRUTTITUM

Emily Govro, MD Advisor: DANIS

Corinne Halsted, MD Advisor: WHITE

Ha Hatley, MD Advisor: HOEKZEMA

Adam Reinagel, MD Advisor: CAMPBELL

Shivi Yadava, MD Advisor: WILFLING

Second-Year Resident Physicians | Class of 2021

Chelsea Drissell, MD Advisor: WHITE

Vanessa Murillo, MD Advisor: PHRUTTITUM

Kris Pullam, MD Advisor: WILFLING

Larry Rudolf, MD Advisor: DANIS

Amanda Schumacher, DO Advisor: HOEKZEMA

Kevin Sidhu, DO Advisor: VERRY

Third-Year Resident Physicians | Class of 2020

Robyn Brownell, MD Advisor: CAMPBELL

Dallas Chase, MD Advisor: VERRY

Kyle Johnson, DO Advisor: WILFLING

Whitney Knapp, DO Advisor: DANIS

Kim McClure, MD Advisor: WHITE

Ryan Menchaca, MD Advisor: HOEKZEMA

Your life is our lifeâ&#x20AC;&#x2122;s work.

STL_37046 (7/16/19)

MO-AFP.ORG 35

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MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019

Terry Suppes, DO

Daniel Haire, DO

Ashley Cefalu, DO

Samer Abu-Amer, MD

Rachel Allen, MD

Tiffany Bland, MD

Cristianna Abilez, MD

Faculty

Kavitha Arabindoo, MD, MPH

Mark Suenram, MD

Jennifer Tieman, MD, Program Director

Tricia Fairchild, MD

Brent Hrabik, MD

Jennifer Kelley, MD

Sandra Lepinski, MD

Conrad Bajor, DO

Addia DeAllie, MD

Rachel McDonald, MD

Julie Wood-Warner, PhD

Stephanie Baker, DO

Oscar Lu, DO

Sabrina Sahadevan, MD

Class of 2020

Ben Saylor, DO

Ziva Patt-Rappaport, DO

Gretchen Beer, DO

Long Bui, DO

Class of 2022

Sarah Otter, DO

Class of 2021

Joseph Sayegh, MD

Arian Culp, MD

Logan Rice, MD

Rhiannon Talbot, DO

Nicholas Comninellis, MD, MPH

Gazala Parvin, MD

Katherine Field, DO

Emily Stoll, DO

Chelsea Willis, DO

Stephanie Schauner, PharmD

Don Philgreen, MD

Anne Sly, MD

Alexander Gabrovsky, MD

Jessica Testa, DO

Christine Khong, MD

Sabina Lin, DO

Anne Valburg, MD

Kayt McDaniel, MD

James Sweeney, DO

Dianne Winter, DO

Sean Rutschke, DO

2019-2020 R3 CHIEF RESIDENTS

Tatum Mead, PharmD

Adjunct Faculty

INMED Institute for International Medicine Founder & CEO

Shari Ommen, MD

RESEARCH FAMILY MEDICINE RESIDENCY 2020-2022

Valerie Duff, DO

FOR MORE INFORMATION ON OUR PROGRAM, FACULTY AND RESIDENTS VISIT OUR WEBSITE AT WWW.RESEARCHRESIDENCY.COM

Patrick Akin, DO

Angie Chuda, DO

Emily Hansen, DO

Casey Tramp, MD

Revathi Bhat, MD

SAINT LOUIS UNIVERSITY SaintMEDICINE Louis University FAMILY RESIDENCY Family Medicine 2019-2020Residency 2019 - 2020 Daniel Stevens, DO–PGY3 Chief Resident Des Moines University

Randy Jackson, MD–PGY3 Chief Resident Rutgers University

Kelly Dye, MD–PGY3 Texas Tech

Bob Hieger, MD–PGY3 Saint Louis University

Peter Ireland, MD–PGY3 St. Louis University

Nesa Mohebpour, MD–PGY3 University of Texas

Michael Baltes, MD–PGY1 Saint Louis University

Mindy Guo, MD–PGY2 Washington University

John Heafner, MD–PGY2 Saint Louis University

Yu Jen Lun, MD–PGY2 Saint Louis University

Rebecca Rada, DO–PGY2 Kansas City University of Medicine & Biosciences

Marina Tawfik, MD–PGY2 Saint Louis University

Jacquelyn Bailey, MD–PGY1 University of Arkansas

Marco Garcia, DO–PGY1 William Carey University

Jacob Lanter, MD–PGY1 Southern Illinois University

Antonio Rosales, DO–PGY1 Des Moines University

Alexandra Sawicki, DO–PGY1 University of Pikeville

At SSM Health St. Mary’s Hospital 6420 Clayton Road, Room 2234 St. Louis, MO 63117 (314) 951-7230 Hannah Webber, MD–PGY1 University of MissouriColumbia

MO-AFP.ORG 37

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MISSOURI FAMILY PHYSICIAN FALL ISSUE 2019

Hong Nguyen, MD University of Kansas

Bhavishya Narotam, DO Kansas City University

Helen Hill, DO, MPH UMKC Family Medicine Advanced OB Fellow

Sarah Michaels, DO Kansas City University

Hannah Anderson, MD UMKC Family Medicine Advanced OB Fellow

Maranda Nguyen, DO Kansas City University

Andrew Kwan, MD, MBA University of Kansas

Jessica Braure, MD, PhD UFR des Sciences Médicales de l’université de Bordeaux

Nissy Phillip, MD St Peter’s University Hosp Rutgers-Robert Wood Johnson Geriatric Medicine Fellow

Christopher Koehn, DO, MBA Kansas City University

Sonia Hussain, MD SABA University

Sara Howe, MD University of MO-Columbia

Rebecca Aguayo, MD University of MO-Columbia

Seenu Abraham, MD UMKC

Brandon Abbott, DO ATSU Kirksville

Michael Nordquist, DO Des Moines University

Taylor Lacy, MD UMKC

Crystal Brown-Vredenburg, MD University of KS-Wichita

Carlos Pacheco III, MD University of Kansas

LiYin Lan, DO, MBA Kansas City University

William Burkhart, MD East Tennessee St

Stacey Leber, DO Des Moines University

Holly Perkins, MD Creighton

Monica Paulson, DO Kansas City University

Carolyn Coyle, MD University of Texas

Peter Lazarz, MD UMKC

Spencer Cline, DO Kansas City University

Jarom Spencer, DO Des Moines University

Nicole Lee, MD University of Virginia

Elizabeth Dedon, DO Kansas City University

UMKC FAMILY MEDICINE RESIDENCY TRUMAN MEDICAL CENTER - LAKEWOOD 2020-2022

Ian Hallows, DO Providence Hospital & Medical Center Sports Medicine Fellow

Daniel Purdom, MD UMKC Family Medicine Geriatric Medicine Fellow

Joseph Karas, DO, University of Illinois College of Medicine Sports Medicine Fellow

Joshua Williams, MD UMKC Marshall Taylor, DO Oklahoma St University Steven Taki, MD University of Washington

Matt Hendrix, MD UMKC

Cheyenne McKahan, DO ATSU Kirksville

Joshua Go, DO Kansas City University

Whitnee Maycock, MD University of Texas

Bailey Martin, MD University of MO-Columbia

Jordyn Ginter, MD

Chicago Medical School Rosalind Franklin University

7900 Lee's Summit Road Kansas City, MO 64139 Ph: 816-404-7751 Fax: 816-404-7756 Email: info@umkcfm.org

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Self-Study CME Revenue Share Improve patient care and bridge your knowledge gaps with AAFP selfstudy CME—when and where it’s convenient for you—and help your chapter earn additional revenue through the AAFP Self-Study CME Revenue Share program.

Clinical Packages Use AAFP self-study packages to enhance your expertise and expand your knowledge on common family medicine topics.

Featuring recorded audio and video presentations from current AAFP live clinical courses, these interactive self-study packages take approximately 20-45 hours to complete and include: • 18-43 lectures between 30 and 60 minutes in length • Opportunities to report CME and evaluate after each lecture • Interactive interface with QuestionPause™ to briefly halt the presentations • Post-test (online)

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Includes a USB Flash Drive, audio CDs with select packages, and a print and PDF color syllabus. *Online access valid one year from purchase date of online-inclusive package.

How to Benefit Your Chapter through the AAFP Revenue Share Program

At checkout, add 4MYCHAPTER in the source code box and a portion of your purchase revenue will be shared back with your chapter.