Fall 2016 (October-December)

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician October-December 2016 Volume 35, Issue 4

24th Annual Fall Conference Schedule and registration form page 12

National Conference recap page 10

Congress of Delegates recap page 23

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executive commission Board Chair - Peter Koopman, MD, FAAFP (Columbia) President - Kathleen Eubanks-Meng, DO (Blue Springs) President-Elect - Mark Schabbing, MD (Perryville) Vice President - Sudeep Ross, MD (Kansas City) Secretary/Treasurer - James Stevermer, MD, FAAFP (Fulton) board of directors District 1 Director: John Burroughs, MD (Kansas City)

Alternate: Jared Dirks, MD (Kansas City) District 2 Director: Lisa Mayes, DO (Macon)

Alternate: Vacant District 3 Director: Caroline Rudnick, MD (St. Louis)

Director: Sarah Cole, DO (St. Louis)

Alternate: Kara Mayes, MD (St. Louis) District 4 Director: Jennifer Scheer, MD, FAAFP (Gerald)

Alternate: Kristin Weidle, MD (Washington) District 5 Director: Lucas Buffaloe, MD (Columbia)

Alternate: Vacant District 6 Director: Jamie Ulbrich, MD, FAAFP (Marshall)

Alternate: David Pulliam, DO, FAAFP (Higginsville) District 7 Director: Vacant

Director: Afsheen Patel, MD (Kansas City)

Alternate: Ryan Sears, DO (Lee's Summit) District 8 Director: Mark Woods, MD (Ozark)

Alternate: Charlie Rasmussen, DO, FAAFP (Branson) District 9 Director: Patricia Benoist, MD, FAAFP (Houston)

Alternate: Vacant District 10 Director: Deanne Siemer, MD (Jackson)

Alternate: Vicki Roberts, MD (Cape Girardeau) Director At Large Emily Doucette, MD (St. Louis)

MARK YOUR CALENDAR MAFP 24th Annual Fall Conference & KSA Working Group November 4-6, 2016 Big Cedar Lodge, Ridgedale, MO Multi-State Forum February 11-12, 2017 Grand Hyatt DFW, Dallas, TX MAFP Advocacy Day February 28-March 1, 2017 Capitol Plaza Hotel/ Missouri State Capitol Jefferson City, MO AAFP Annual Chapter Leadership Forum/National Conference of Constituency Leaders April 27-29, 2017 Sheraton Kansas City Hotel at Crown Center, Kansas City, MO AAFP Family Medicine Congressional Conference May 22-23, 2017 Washington Court Hotel, Washington, DC

MAFP Board of Directors Meeting June 11, 2017 The Lodge at Old Kinderhook, Camdenton, MO AAFP National Conference of Family Medicine Residents & Students (NCFMRS) July 27 – 29, 2017 Kansas City Convention Center, Kansas City, MO AAFP Congress of Delegates September 11-13, 2017 Grand Hyatt, San Antonio, TX AAFP Family Medicine Experience (FMX) September 12-16, 2017 Grand Hyatt, San Antonio, TX MAFP 25th Annual Fall Conference & KSA Working Group November 10-11, 2017 Big Cedar Lodge, Ridgedale, MO

MAFP 69th Annual Scientific Assembly (ASA) June 9-11, 2017 The Lodge at Old Kinderhook, Camdenton, MO

resident directors Kanika Turner, MD (SLU) Alicia Brooks, MD (Alternate) (SLU) student directors Emily Gray (UMKC) John Heafner, MSPH (Alternate) (SLU) aafp delegates David Schneider, MD, FAAFP, Delegate Todd Shaffer, MD, MBA, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate mafp staff Executive Director - Kathy Pabst, MBA, CAE Communications and Education Manager - Sarah Mengwasser Membership and Programs Coordinator - Becki Hughes Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 f. 573.635.0148 www.mo-afp.org office@mo-afp.org The information contained in Missouri Family Physician is for information 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 opinion expressed in each article(s) is the opinion of its author(s) and does not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.

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INSIDE THIS ISSUE Pg. 4 President's Report 6 Resident Grand Rounds 8 Help Desk Answers 10 National Conference Recap 12 24th Annual Fall Conference Schedule and Registration Form 15 Member Input 16 Members In The News 19 Reducing Risk 20 Opioid Epidemic 22 Student Externship 23 Congress of Delegates Recap 24 Keith Ratcliff on COD 26 Catherine Moore, DO Award 28 Residency Composites

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PRESIDENT'S REPORT

What does the Missouri Academy do for me?

T Kathleen EubanksMeng, DO

4

he alarm often goes off before 5 am, the text messages and emails have been hitting my phone and inbox all night as the world of technology doesn’t need to sleep. My family is all out the door mostly before 6:30 am and the day begins. I am fortunate to work in a busy suburban practice with an amazing nurse team and physician partners. My day ends well after 5:00 pm and often involves a few hours of work late into the night hours after the soccer, band, and volleyball practices occur, thanks to the EHR. Medicine has changed significantly since I started my journey in the 90s. I am thankful for the opportunity to be able to do “paperwork” at home, but the balance of work and home definitely has a challenging twist. As I shared with our colleagues at the National Conference of Constituency Leaders from across the United States, as well as our own Missouri colleagues at our summer conference at the lake, a common theme amongst all physicians existed: How do we “keep up” with all of the changes in medicine, and what resources do the Missouri Academy and American Academy give me with my membership? Where can I find resources to help me navigate through this? Your Missouri Academy has resources to help you get through your day-to-day practice as well as helping you navigate through the changing world of family medicine.

The Missouri Academy provides support via website and social medial on Twitter as well as Facebook and Instagram. They also are only a phone call away if you prefer the personal touch or person-to-person contact. The Missouri Academy continues to provide continuing medical education resources with face-to-face conferences in June and November as well as access to online resources. However, they also provide the opportunity to have influence on state government by participating in Advocacy Day in February and March, and the opportunity to have face-toface meetings with your state representatives and senators. If you don’t have time to be away, they offer connections through our lobbyist Pat Strader, email connections, and postal “snail mail”

MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

information for your state and national senators and representatives.

Any member can also participate in one of three state commissions that meet face-to-face three times per year and as needed by phone conference or email. The Advocacy Commission discusses legislative issues that will ultimately affect your day-to-day practice. The commission provides coaching to assist with testifying to your legislators as well as how to develop individual relationships with your legislators. It is your choice to be as active as you need to be. The Education Commission provides opportunities for you to connect with local and national speakers, provide content information for the face-to-face conferences, and allows you the opportunity to speak at the fall or summer conference if this is one of your strengths or talents. Membership Services Commission also provides opportunity for those that would like to use their journalism skills and peer review skills for the award winning quarterly magazine. This commission also participates in judging for the Missouri Family Physician of the Year. The Executive Commission meets three times per year face-to-face and

"

In the overwhelming and busy world in which we advocate for our families, our patients and ourselves, we are here for you."

monthly in phone conferences. This commission consists of the board officers and your executive director. The Board of Directors is comprised of geographical districts and you have the opportunity to participate in a board position as a director or an alternate board member. There are also medical student and resident positions as well as at-large appointed positions. The board meets with three face-to-face meetings per year and at times maybe called upon for further

mafpPAC face-to-face meetings or email communication.

If you have a desire to serve in a leadership position please contact one of your board officers or Kathy Pabst, our executive director, for more information.

Priority to our members is increasing overall payment for family physicians, working within the health care reform law, helping family physicians maintain board certification, preserving the full scope of practice for family physicians, protecting family physicians’ interests with regard to non-physician providers, supporting meaningful medical liability reform, and improving access to health care in rural and underserved communities. Each commission focuses on these issues at state and national levels. The AAFP has member interest groups in adolescent health, direct primary care, emergency medicine and urgent care, global health, hospital medicine, independent and small group practice, lifestyle medicine, oral health, point of care ultrasound, reproductive healthcare, rural health, school health, single payer health care, telehealth, and transforming clinical practice initiative. If you feel you can serve in this way, there is opportunity.

We continue to work for you and we want your input. In the overwhelming and busy world in which we advocate for our families, our patients and ourselves, we are here for you.

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RESIDENT GRAND ROUNDS

Acute disseminated encephalomyelitis associated with Influenza Type B infection

John Ballantyne, MD, PGY3 Resident Physician

Megan Warhol, DO, PGY3 Resident Physician

Laura Morris, MD, MSPH Faculty Advisor University of Missouri - Columbia

6

INTRODUCTION Acute disseminated encephalomyelitis (ADEM) is an autoimmune inflammatory disease involving white matter demyelination in the brain and spinal cord. The condition is usually preceded by a viral infection and presents with multifocal neurologic disturbances and altered levels of consciousness.1-2 Young adults and children are most commonly affected. MRI is the investigation of choice, classically revealing bilateral asymmetrical frontal and parietal lobe lesions.2,3 Treatment with high-dose IV methylprednisolone usually results in rapid recovery. We will review the case of a two-year old male diagnosed with ADEM following Influenza B infection.

Previous studies established that the influenza virus represents a common causative agent of ADEM, but influenza B is much less frequently associated with the condition.10 CASE PRESENTATION A two-year old previously healthy Caucasian male presented to the ER with a ten-day history of flu-like illness. Initial symptoms included fever and cough then subsequently progressed to mutism, ataxia, and generalized hypertonia with resting tremor. At time of presentation, the patient was afebrile and vitals were within normal limits. His respiratory, cardiovascular and abdominal exams were unremarkable. Musculoskeletal exam was notable for fixed, flexed positioning of the bilateral arms and legs. Neurologic exam revealed diffuse hypertonia bilaterally with spasticity that was more pronounced in the lower extremities. The patient had diffuse hyperreflexia, clonus in ankles and wrists and a fine resting tremor in the left hand and lower jaw. Lab work including CBC, CMP, lead level, lactic acid, CRP and ESR were all within normal limits. Nasopharyngeal swab for Influenza B was positive. Lumbar puncture and electroencephalography were unremarkable.

MRI brain and spinal cord revealed bilateral fluid-attenuated inversion recovery (FLAIR) hyperintense signal in the bilateral corona radiata and thalamic region. The patient was started on a five-day course of methylprednisolone 25mg/kg/

MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

day and demonstrated progressive improvement of symptoms. Upon completion of the steroid course, the child had brisk deep tendon reflexes, but otherwise no residual neurologic deficits. At a two-month follow up appointment, the patient demonstrated only mild bilateral ankle clonus but was otherwise free of neurologic sequelae.

DISCUSSION Epidemiology: ADEM can occur at any age, but is diagnosed more often in pediatric patients than in adults. The mean age at presentation in children ranges from five to eight years of age.1,2,4,6 Although there does not seem to be a strong correlation with gender, two pediatric cohort studies suggested a possible male predominance, with reported female to male ratios of 0.6 and 0.8, respectively.5,6 A recent study completed in California estimated the mean incidence of ADEM as 0.4/100,000 per year among persons less than 20 years of age living in that region.7 Clinical Features and MRI Findings: Classically, ADEM is a monophasic disorder that begins between two days to four weeks after antecedent infection or vaccination.1 The typical signs and symptoms of ADEM include a rapid onset of encephalopathy with multiple potential neurologic manifestations. The most common neurologic findings include unilateral or bilateral pyramidal signs (60 to 95%), acute hemiplegia (76%), ataxia (18 to 65%), cranial nerve palsies (22 to 45%), visual loss secondary to optic neuritis (7 to 23%), seizures (13 to 35%), spinal cord involvement (24%), impairment of speech (5 to 21%), and hemiparesthesia (2 to 3%). Mental status can range from lethargy to coma.1, 2, 4-7 Overall, there is wide variation in the severity of the illness. MRI using T2-weighted FLAIR imaging has become a sensitive and important tool for the diagnosis of ADEM.9 White matter lesions are typically multiple and asymmetrical, while gray matter lesions tend to be symmetrical and often involve the thalamus and the basal ganglia.2,6

RESIDENT GRAND ROUNDS Figure 1: Axial T2-weighted MRI demonstrating symmetric increased signal in bilateral thalami, with involvement of the insula and subcortical white matter, in an 18-month-old boy, 3 weeks after having mumps.1

Table:

RESOURCES Diagnosis: Historically, there has been a lack of consensus regarding the definition of ADEM and the radiologic criteria used to make the diagnosis.

In the absence of specific biologic markers, the diagnosis of ADEM is still based on the clinical and radiologic features. Although ADEM usually follows a monophasic course, recurrent forms have been reported. This makes differentiation from other clinical conditions such as multiple sclerosis more difficult.1 In order to move toward a more uniform classification system, the International Pediatric Multiple Sclerosis Study Group proposed that three terms be used to characterize variations of ADEM. (see Table above) Treatment and prognosis: Steroids are the mainstay of treatment; however, there is significant variation in the formulations used, routes of administration, dosing, and tapering regimens. Most publications suggest high-dose corticosteroid treatment, usually methylprednisolone given at 20–30 mg/kg/day or dexamethasone (1 mg/kg) for three to five days.2,6,11 Immunomodulation may be effective, including IVIG (total dose of 1-2 g/kg, over 2 to 5 days) and plasma exchange (five to seven sessions over 7 to 10 days).1,9 Generally, patients diagnosed with ADEM have a favorable outcome with minimal to no long term neurologic sequelae.

When reevaluated more than 3 years after diagnosis of ADEM, subtle neurocognitive deficits in attention, executive function, and behavior may persist.1

1) Tenembaum S, Chitnis T, Ness J, and Hahn, JS. Acute Disseminated Encephalomyelitis. Neurology. 2007 Apr 17;68(Suppl 2):S23–S36.

2) Hynson JL, Kornberg AJ, Coleman LT, Shield L, Harvey AS, Kean MJ. Clinical and neuroradiologic features of acute disseminated encephalomyelitis in children.

Neurology 2001;56:1308–1312.

3) Miller DH, Robb SA, Ormerod IE, et al. Magnetic resonance imaging of inflammatory and demyelinating white-matter diseases of childhood. Dev Med Child Neurol. 1990 Feb;32(2):97–107.

4) Anlar B, Basaran C, Kose G, et al. Acute disseminated encephalomyelitis in children: outcome and prognosis. Neuropediatrics 2003; 34: 194–199.

5) Murthy KSN, Faden HS, Cohen ME, Bakshi R. Acute disseminated encephalomyelitis in children. Pediatrics 2002;110:21–28.

6) Tenembaum S, Chamoles N, Fejerman N. Acute disseminated encephalomyelitis: a long-term follow-up study of 84 pediatric patients. Neurology 2002;59:1224–1231.

7) Leake JAD, Albani S, Kao AS, et al. Acute disseminated encephalomyelitis in childhood: epidemiologic, clinical and laboratory features. Pediatric Infect Dis J 2004;23:756–764.

8) Wingerchuk DM. Postinfectious encephalomyelitis. Curr Neurol Neurosci Rep 2003;3:256–264.

9) Steiner L, Kennedy PG. Acute disseminated encephalomyelitis: current knowledge and open questions. J Neurovirol. 2015 Oct;21(5):473-9.

10) Morishima T, Togashi T, Yokota S, et al. Encephalitis and encephalopathy associated with an influenza epidemic in Japan. Clin Infect Dis. 2002 Sep 1;35(5):512-7.

11) Dale RC, de Sousa C, Chong WK, Cox TC, Harding B, Neville BG. Acute disseminated encephalomyelitis, multiphasic disseminated encephalomyelitis and multiple sclerosis in children. Brain. 2000 Dec;123:2407–22.

Consulting packages are available, providing our proven business model to help build a strong DPC clinic providing exceptional and affordable care to all.

Contact Dr. Jenny Powell at (573) 933-0872 or (417) 664-5054.

ATTENTION RESIDENTS: NEED TO BE PUBLISHED?

Submit your report to be published as a Resident Grand Rounds article in our quarterly Missouri Family Physician magazine. Contact MAFP: office@mo-afp.org

DPCareClinics.com MO-AFP.ORG 7

HDAs HelpDesk Answers

Is Cytisine effective for smoking cessation?

EVIDENCE-BASED ANSWER

Cytisine is up to three times more effective than placebo for smoking abstinence (SOR: A, meta-analysis of RCTs) and noninferior to nicotine replacement therapy (SOR: B, single noninferiority trial). Sustained quit rates decline from 40% at 1 month to 8.4% at 12 months.

A

EVIDENCE SUMMARY

Sarah Kirchoff, MD

Laura Morris, MD, MSPH University of Missouri Family Medicine - Columbia

8

2013 meta-analysis of 7 RCTs (N=4,020) compared cytisine versus placebo for smoking cessation.1 Standard cytisine dosing is a tapered regimen of 1.5-mg tablets taken over 25 days during which patients stop smoking by day 3 to 5 (see TABLE). Cytisine, either alone or combined with varying levels of behavioral support, was more effective than placebo with or without behavioral support, for smoking abstinence at follow-up times ranging from 26 days to 2 years (RR=1.6; 95% CI, 1.4–1.8). A subgroup analysis including the 2 highest quality RCTs (n=911) with intention-to-treat analysis and verification of smoking status biochemically showed cytisine was more effective than placebo for smoking abstinence at 6 months (RR 3.3; 95% CI, 1.8–5.9).1 Treatment with cytisine caused more gastrointestinal adverse events (AEs) than placebo, but there was no significant difference in overall AEs. Trials ranged from low to high quality. Lower quality studies had no validation of abstinence, unclear blinding, no placebo, and lack of concealed allocation.1 The longest study with validation of abstinence in the above meta-analysis was a double-blinded RCT of 740 adults who smoked 10 or more cigarettes per day and were interested in quitting.2 Patients were randomized to cytisine or placebo for 25 days.

Complete data were available for 77% of patients. At 12 months, biochemically verified smoking abstinence was 8.4% in the cytisine group versus 2.4% (P≤.001) in the placebo group (NNT=17).2 A 2014 noninferiority RCT included 1,310 adult daily smokers recruited through a national quit line randomized to standard cytisine dosing for 25 days or nicotine replacement therapy (NRT) with patches, gum, or lozenges for 8 weeks.3 The type and strength of NRT was decided by participant preference and quit line advisors in accordance with national smokingcessation guidelines. Both groups were offered lowintensity telephone behavioral support. One month after the set quit date, continuous self- reported abstinence rates in the cytisine group were 40% compared with 31% in the NRT group (risk difference [RD] 9.3%; 95% CI, 4.2–14.5; NNT=11). Secondary outcomes in this study included continuous abstinence rates at 2 months (31% for cytisine vs 22% for NRT;

MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

RD 9%; 95% CI, 4.3–13.8; NNT=11) and 6 months (22% for cytisine vs 15% for NRT; RD 6.6%; 95% CI, 2.4–10.8; NNT=14).3

1. Hajek P, McRobbie H, Myers K. Effi of cytisine in helping smokers quit: systematic review and meta-analysis. Thorax.

2013; 68(11):1037–1042. [STEP 1] 2. West R, Zatonski W, Cedzynska M, et al. Placebocontrolled trial of cytisine for smoking cessation. N Engl J Med. 2011; 365(13):1193–1200. [STEP 2] 3. Walker N, Howe C, Glover M, et al. Cytisine versus nicotine for smoking cessation. N Engl J Med. 2014; 371(25):2353–2362. [STEP 2]

Interested in more HelpDesk Answers?

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PRESIDENT'S REPORT

Missouri Family Physician October-December MO-AFP.ORG 2015 99

FAMILY MEDICINE IN MOTION FAMILY MEDICINE IN MOTION FAMILY MEDICINE IN MOTION FAMILY MEDICINE IN MOTION

NATIONAL CONFERENCE RECAP

Family Medicine in motion; another successful National Conference

T

he National Conference of Family Medicine Residents and Medical Students took place in Kansas City, July 28-30 with final attendance around 4,500. Missouri Street in the exhibit hall was a hit with six Missouri residency programs recruiting medical students to come to the Show Me state.

Missouri residents and students were elected at the Missouri Reception on July 29 to serve as alternate board members on the MAFP Board of Directors. John Heafner, MSPH, a student at Saint Louis University, was elected as the alternate student director, and Alicia Brooks, MD, Saint Louis University, will serve as the alternate resident director. They will assume the director position next July when Emily Gray (student director) and Kanika Turner, MD (resident director) terms expire. Other national leadership positions were also filled during this conference.

This year’s conference brought about resolutions on protecting patient’s rights, rural training options, mental wellness and burnout among medical students, and an end to the United States Licensing Examination Step 2 Clinical Skills requirement for graduates of U.S. medical schools.

These, and other resolutions, will move through the AAFP’s policymaking process.

Health is Primary hosted a panel discussion during the conference that was moderated by author and journalist, T.R. Reid. The panel featured Natasha Bhuyan, MD, Phoenix, AZ; Jennifer Brull, MD, Plainesville, KS; and Zubin Damania, MD, (aka ZdoggMD) Las Vegas. ZdoggMD premiered a new music video that describes his journey through medical school and the effect caring for patients has had on his life (visit www. healthisprimary.org to view the video). The panel discussed the culture of medical school that discourages students from choosing primary care as a speciality; family physicians are the solution to our healthcare problems; and the importance of advocacy and engagement.

10

MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

Concurrently with this panel discussion, Todd Shaffer, MD, FAAFP, MAFP past president, was being interviewed on the healthcare workforce shortage by KCUR radio and Fox4KC television station. Check out the MAFP Facebook page for links to these interviews.

Funding for FMIGs Family Medicine Interest Groups (FMIGs) can receive $600 for the 2016–17 academic year from the AAFP and AAFP Foundation. The application process is open for the FMIG Funding Initiative, which provides much-needed assistance to FMIGs working to build student interest in family medicine on college campuses across the country.

Eligibility requirements for an FMIG to qualify are available. Groups are free to use the funds for any purpose they choose (e.g., meals for meetings, funds for students to attend regional and national meetings, or supplies for fundraisers).

Some level of chapter involvement is required, and additional chapter involvement to help medical schools deliver quality programming is encouraged. Chapter involvement might include the following: • Collect and distribute the funds (the AAFP can write a check to chapters instead of the school).

• Bring guest physicians to the schools to speak on family medicine.

• Ensure a school completes the required application and materials by the December 9, 2016 deadline.

Program details and materials are available.

Contact Mary Harwerth by email at mharwerth@ aafp.org or ext. 6751 with questions.

NATIONAL CONFERENCE RECAP

2

1

1. Health is Primary panel discussion.

2. Missouri Street in motion.

3. Standing ovation for ZdoggMD's video release.

4. Residents enjoying the Missouri Reception.

5. Emily Gray and John Heafner.

6. Sandhu Jeena Porter's poster presentation.

7. Alicia Brooks, MD, newly elected MAFP alternate resident director and Kanika Turner, MD, director.

3

4 5

6

7

24FAallnnCuoanlference th

New this y

ear!

SCHEDULE OF EVENTS

*All lectures will be held in Grandview Ballrooms C & D*

Thursday, November 3 4:00 pm - 6:00 pm

Registration NEW! Early (Grandview Conference Center)

Join MAF P Ozark Mo at the Beer Tas untain ting eve Suppor t the Famil nt. yH Foundati on of Mis ealth souri.

Friday, November 4

Saturday, November 5

7:00 am - 8:00 am Registration and Breakfast Buffet with Exhibitors

(Grandview Ballrooms A and B)

7:00 am - 8:00 am Registration and Breakfast Buffet with Exhibitors

(Sponsored by Midwest Dairy Council)

(Grandview Ballrooms A and B)

8:00 am - 8:45 am

Falling Off the Curve – Failure to Thrive Robert Rothbaum, MD

8:45 am - 9:45 am

Integrating Behavioral Health into Primary Care Settings Russell Kohl, MD, FAAFP and Mary Ann Kimbel

9:45 am - 10:30 am

Refreshment Break with Exhibitors (Sponsored by Direct Primary Care Clinics)

10:30 am - 11:15 am

MACRA, MIPS, and APMs – How AAFP is Positioning You Shawn Martin, Senior Vice President, AAFP, Advocacy, Practice Advancement and Policy

11:15 am - 12:00 pm

Office Use of the Hyfrecator Robert Buffaloe, MD

12:00 pm - 1:00 pm

Working Lunch - Employing EvidenceBased Strategies for Diagnosing and Managing Patients with Psoriasis: The Role of the Primary Care Clinician Steven R. Feldman, MD, PhD (Sponsored by Peer Review Network)

1:00 pm - 1:15 pm

Break

1:15 pm - 2:00 pm Controversy in Prostate Cancer Smart

Screening Recommendations for African

Americans and Men – Interpreting the Data

Lannis Hall, MD 2:00 pm - 2:45 pm

A New Model for Chronic Care – An Introduction to Functional Medicine Casey Tramp, MD

2:45 pm - 3:00 pm

Break

3:00 pm - 3:45 pm

Introduction to Obesity Medicine Justin Puckett, DO, FACOFP, FAAFP

3:45 pm - 4:30 pm

Coordinating Care in IBD: Diagnosis and Co-Management Strategies for Family Physicians (Sponsored by North Carolina AFP) Joel J. Heidelbaugh, MD, FAAFP, FACG

4:30 pm - 5:15 pm

Therapy – Back to Basics Brian Mahaffey, MD, FAAFP

6:30 pm - 7:30 pm

Ozark Mountain Beer Tasting (Worman Room) Learn about crafting beer from microbreweries in the Ozark Mountains. $50 per person. Proceeds go to the FHFM.

8:00 am - 8:45 am

Using Hand-Held Devices and Apps to Improve Primary Diagnoses and Patient Engagement in the Exam Room David Voran, MD

8:45 am - 9:30 am

Successfully Precepting Medical Students in a Community Practice Miranda Huffman, MD; Steve Griffith, MD, FAAFP; and Angela Barnett, MD

9:30 am - 10:15 am

Refreshment Break with Exhibitors (Sponsored by Wilshire Pennington Group)

10:15 am - 11:00 am

Guidelines for the Treatment of Hypertension in Pregnancy Aaron Sinclair, MD, FAAFP

11:00 am - 11:45 am

Treating IBS: Listen, Look and Learn from Your Patients (Sponsored by North Carolina AFP) Joel J. Heidelbaugh, MD, FAAFP, FACG

11:45 am - 12:45 pm

Working Lunch - Integrating Registry Information at the Point of Care to Improve Quality David Voran, MD

12:45 pm - 1:30 pm

Opioid Use Disorder: Trends and Treatment Lucas Buffaloe, MD

1:30 pm - 2:15 pm

Lipid Management and Prevention Strategies: An Evidence-Based Update Brian Williams, MD and Jodi Flynn, PA-C

2:15 pm - 2:30 pm

Break

2:30 pm - 3:15 pm

Knee Osteoarthritis Treatments Brian L. Mahaffey, MD, MSPH, FAAFP

3:15 pm - 4:00 pm Recognizing and Preventing Physician Burnout

Charles Sincox, MD, FAAFP 4:30 pm - 5:30 pm

Commission Meetings (Business Lounge B/Lakeview C)

5:30 pm - 7:30 pm

MAFP Board Meeting (Lakeview A and B)

Sunday, November 6 8:00 am - 2:30 pm

KSA Working Group (formerly SAM): Care of the Vulnerable Elderly (Grandview Ballroom A) James Stevermer, MD, MSPH, FAAFP Paul Tatum, MD

24th Annual Fall ANNUAL Conference Registration Form FALL CONFERENCE Missouri Academy of Family Physicians 722 West High Street, Jefferson City, MO 65101 November 4-5, 2016 Email: | Phone: Big office@mo-afp.org Cedar Lodge 573.635.0830 Fax: 573.635.0148 Want to register online? Visit mo-afp.org

REGISTRATION FORM

AAFP ID: Name:

 MD

 DO

Address:

City/State/Zip:

Telephone:

Email:

 FAAFP

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Full

Amount

MAFP Member* New Physician, Life Member, or Allied Health Professional AAFP Member (Out of State)

$200

 Friday

 Saturday

$375

$

$175

 Friday

 Saturday

$300

$

$210

 Friday

 Saturday

$400

$

Non-Member

$250

 Friday

 Saturday

$475

$

$200

$

$25

$

Total A

$

KSA Working Group

Sunday – (8:00 a.m. – 2:30 p.m.)

Printed Syllabus (Free for Life members)

$25

*AAFP Membership includes state chapter membership.

RSVP Event Conference Attendee (Check all that apply.)

Friday Breakfast

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Saturday Breakfast

Saturday Lunch

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Guests

_____ x $20 Each

_____ x $25 Each

____ x $20 Each

_____ x $25 Each

Total B + Total A Don’t forget Early Bird Discount (received on or before 10/4/16) | -$50 Does not apply to one-day registration or KSA Working Group NEW THIS YEAR! Ozark Mountain Beer Tasting $50 (Optional) MAFP-PAC Contribution (Optional) Family Health Foundation of Missouri 50/50 Raffle (Optional) Tax ID 43-1480324 | $10 per ticket or 6 for $50 Total Amount Due

Amount $

Included

$ $ $ $ $ $ $

Special Dietary Needs or Physical Accommodations: ______________________________________________ Registration Information: • CME sessions, meals, breaks, and electronic syllabus are included in the registration fee. All functions in the Exhibit Hall are for registrants only.

• KSA Working Group includes continental breakfast, lunch and refreshments.

• By registering for this conference, I authorize MAFP to use photographs of me with or without my name for any lawful purpose, including print or online marketing.

• Registration cancellations must be in writing (to office@mo-afp.org) and received no later than October 4, 2016. A $50 administrative fee will be deducted from each refund processed. No refunds will be issued after this date.

Questions? Call (573) 635-0830, Fax (573) 635-0148, or email at office@mo-afp.org Payment Information:

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

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It’s not just an outcome we pursue —but a transformation we lead.

For more information, visit childrensmercy.org/transform

MEMBER INPUT

Paying it forward: One man's prescription for living with Hemophilia

I

know becoming a physician is challenging, but living with hemophilia, pursuing a dream, and not accepting NO for an answer has been my focus over the last decade. Hemophilia A is a bleeding disorder that requires weekly infusions of Factor VIII to prevent bleeding into joints and soft tissues.

I’m here today to let you know that just because you have a chronic disease, doesn’t mean that you have to let it define you. Yes, living with hemophilia has its challenges; but it’s also possible to be proactive about your health and make positive choices.

Helping people and giving back to the hemophilia community is important to me.

In fact, I believe in it so strongly, that I’ve devoted my entire life to helping others. With my history, I feel I could really help my future hemophilia patients. In the grand scheme of things, I feel it’s my calling.

I was diagnosed with hemophilia when I was about six months old. My parents noticed that I seemed to be in pain, and that I was bruising in my knees and ankles. They didn’t know it at the time, but I was having a bleed. They took me to the pediatrician, drew some labs, and found out that I had severe hemophilia A. My parents learned that my mother was a carrier and my younger brother would also be diagnosed with hemophilia 13 years later.

As a child, my parents treated me on demand, and by the time I turned 12, I’d learned how to self-infuse; I averaged about two bleeds a week. I admit that as a kid, I didn’t always use the best judgement, and consequently, I had three serious bleeds during my childhood. Growing up, I had a lot of careless accidents, like when I fell and broke my arm the day before my first baseball game. All in all, I had two shoulder synovectomies and still suffer from arthritis in my ankles.

I confess, I probably had so many bleeding episodes because I didn’t always listen to my parents. I just wanted to be a normal kid. Despite all the bleeds, I had great parents who loved and supported me unconditionally. They wiped away my tears and listened to my troubles when I was bullied in school. It was hard to explain my condition to my classmates; when I was on crutches one day, but seemed okay the next, only to miss several more days of school. They thought I was playing hooky, when

in reality, I had a bleed. Looking back, I hated school at times because I was an easy target, but as much as I hated to hear all of the snickering, I never let it show. Never… I had to be strong…

Things started to change for me around the time I turned 13.

Then my brother Jake was born. Somehow, I stepped up to the plate to be a big brother and began helping my mom infuse him. I decided to make it my mission to help him understand that happiness is important in life. He would have to make proactive choices about his health as well. I discovered that by mentoring him, it lifted me up. Meanwhile, as he grew, we hung out, watched movies, we’d go fishing, or play video games at the

"

I refuse to let hemophilia define me." arcade. Even though I am very busy with residency, I still play an active role in his life and continually give him guidance and support.

The turning point in my own life happened several years ago when I was a junior in high school. I was at that awkward age and having a tough time; I was still struggling from the bullying and my grades were suffering. But by then, the good thing was that I’d learned to take good care of myself and was in control of my health. Everything changed when I finally decided that I’d had enough of getting bad grades. So I decided to apply myself in math and science, I excelled in these topics, and earned my first 4.0. That’s when I began to think, "How can I use my abilities to help other people and make a better life for myself?"

The answer? I want to become a doctor.

I feel very fortunate to be where I am today, which is why I believe in giving back. I’ve been involved with the hemophilia community in numerous ways over the years. Most recently, I volunteered at Camp Notaclotamongus (Get it?—Not a Clot Among Us). I counseled and encouraged kids who were learning to self-infuse to make that next big step in their lives and gain their independence. What an amazing experience -- I plan on attending in the future years to come.

When I look back, I realize hemophilia has shaped me into the man I am today. Still, to this day, I refuse to let hemophilia define me. Sure, I have to be aware of my limitations, but I continue to strive to be proactive about my health, make a difference in the hemophilia community, and pay it forward. I hope that you will too.

Joseph Moleski is a second year resident at Saint Louis University-Family Medicine.

If you would like to submit a story for Member Inout, please email office@mo-afp.org and MAFP will review content for publication.

MO-AFP.ORG 15

MEMBERS the

IN NEWS NEWS TO SHARE?

The Missouri Family Physician magazine welcomes your input.

Please submit newsworthy items for review to: office@mo-afp.org

LeFevre nominated to serve on CDC Advisory Committee On August 3, the AAFP nominated Michael LeFevre, MD, MSPH to serve on the Centers for Disease Control and Prevention’s Advisory Committee to the Director. Dr. LeFevre has been a member of the U.S. Preventive Services Task Force since January 2005 and was appointed chair of the Task Force in March 2014. He became the immediate past chair in March 2015.

Michael L. LeFevre, MD, MSPH

UMKC receives ACGME Osteopathic Recognition University of Missouri - Kansas City (UMKC) is the first Missouri Family Medicine program to receive initial recognition status for ACGME Osteopathic Recognition. UMKC is affiliated with Kansas City University (KCU) for post-graduate medical osteopathic education. KCU provides a workshop during orientation to review and assess OMM skills. KCU's own osteopathic faculty provide teaching throughout all clinical settings and during learning sessions.

Osteopathic residents are encouraged to utilize their osteopathic skills and knowledge to diagnose and treat patients in all practice settings. Residents participating in the osteopathic recognition track will staff OMT clinic an average of 1x/month and are encouraged to perform OMT on continuity clinic patients when applicable.

Residents who participate in the osteopathic recognition track are eligible to sit for boards for both the American Board of Family Medicine and the American Osteopathic Board of Family Physicians. They may take both board examinations, or choose to sit for one board exam of their choice.

OMT interest group is held once a block as a forum for all interested residents to learn basic OMM skills, and for osteopathic recognition track residents and faculty to share OMM skills and expertise.

MU and SLU FMIG's earn Program of Excellence Award MU and SLU FMIG's were two of ten receipients to earn the Program of Excellence Award for 2016. For more than 10 years, the AAFP Family Medicine Interest Group (FMIG) Network has recognized FMIGs with the Program of Excellence Award for their efforts to stimulate student interest in family medicine and family medicine programming.

To win this award, an FMIG must demonstrate that it is well-rounded with competency in a number of key areas, including: FMIG structure and operation, community service, exposing students to family medicine and family physicians, promoting the value of family medicine as primary care, professional development, and measures of success.

The FMIG must also illustrate significant changes or enhancements -- what was learned from the previous years' activities, what new innovations have been or will be developed, and what elements of programming were modified to meet the needs of members.

16

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2016

Meet your newly elected resident and student MAFP Board Members Missouri residents and students were elected at the Missouri Reception on July 29 to serve as alternate board members on the MAFP Board of Directors. John Heafner, MSPH, a student at Saint Louis University, was elected as the alternate student director and Alicia Brooks, MD, at Saint Louis University will serve as the alternate resident director. They will assume the director positions next July when Emily Gray (student director) and Kanika Turner, MD (resident director) terms expire.

From left: Alicia Brooks, MD, Kanika Turner, MD, Emily Gray, and John Heafner, MSPH.

Making Progress: Tobacco 21 Bill passage at county level, now on to St. Louis City St. Louis County Council passed a bill in early September which would cover over a million residents, increasing the age of selling all tobacco products to those who are 21 and older. The Missouri Academy of Family Physicians and the Family Health Foundation signed on in support of this important bill. Their next goal is to focus on passing this bill in St. Louis City. “With 6 other MO cities, 1/3 of Missouri's population is now covered by this policy.

This bill will save approximately 2,500 lives within the County -- 2,500 children (!) who would have grown up and otherwise passed away from tobacco related illness.

Now just extrapolate that into the years to come, and take a (brief) moment to reflect at the thought of your community being that much more healthier, productive, and (someday) unaware of the addiction generations of tobacco users before

them suffered. Thank you, Dr. Sam Page, who introduced this bill in the County and for taking into account the health of so many citizens.� Philip Abraham, MD, FAAP, Washington University, School of Medicine

MO-AFP.ORG 17

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The vaccination challenge vaccinations are the best route, you may want to counsel parents to reconsider vaccinating.

It may be helpful to obtain input from all healthcare providers and staff before implementing a practicewide policy refusing to treat patients whose parents refuse vaccinations. It is important that all healthcare providers are on the same page and agree on such a policy.

Vaccinations can be a difficult topic to discuss. If you have any questions, please call your healthcare professional liability insurer.

As part of ProAssurance's commitment to help healthcare providers reduce risk, they are sharing a series of complete “Physicians’ Responsibility to Obtain Informed Consent” articles.

Copyright © 2016 ProAssurance Corporation. This article is not intended to provide legal advice, and no attempt is made to suggest more or less appropriate medical conduct.

Note: This article, courtesy of ProAssurance, was authored by Jeremy Wale, JD, ProAssurance Risk Resource Advisor.

Some parents do not wish to vaccinate their children, and this has put many practices that treat children in a difficult position.

Some of those practices have made the tough decision to refuse to provide healthcare to those non-vaccinated pediatric patients.

That being said, how do you want to handle established patients whose Do you remember why you became a physician? parents have decided to cease their vaccinations? You have two options: WeCare TLC is looking for quality physicians who are interested in improving the continue to treat the patients or terminate health and wellness of their patients. them from your practice.

WeCare TLC is a medical risk management company that leverages the onsite, Terminating non-vaccinated patients or near site, primary care clinics to save money on health care while improving from your practice is best handled the health and wellness of the employee population. The visits, labs, and delicately by the physician. If you decide medications are free for the employees and their dependents. You will be crucial to do so, it may be best to have several to ensuring that our clinics provide a holistic, convenient, patient-centered conversations to determine if the parents approach. are willing to reconsider before you take action. If the parents hold their position, Highlights of the position: Private practice environment, 20 minute appointment share your decision to end your care, and 40 minute new patient appointments, no nights, no weekends, no insurance explaining you will continue care until forms to hassle with, no claims to disupute. WeCare TLC pays for your Medical such time that the parents are able to find Malpractice Insurance, offers a very competitive salary, excellent benefits another physician. This may require more including medical, vision, dental, Short and Longterm disability and 401-K with company match. than 30 days of care. Offer any assistance you can make available to help these This is the kind or practice you thought you’d have when you first chose primary parents find another physician. care. Come join our team and our mission of becoming a trusted medical home If you decide to continue caring for through improving the health and wellness of our patients. patients whose parents refuse to allow vaccinations, document all conversations If you are interested, please contact Sharon Kraynik at you have with the parents regarding sharon.kraynik@wecaretlc.com or 1.800.941.0644 ext. 957 risks related to the refusal. If you believe MO-AFP.ORG 19

OPIOID EPIDEMIC

McCaskill holds town hall meeting on combating nation's opioid epidemic

I

n response to the Missouri General Assembly’s failure to establish a Prescription Drug Monitoring Program, again, U.S. Senator Claire McCaskill and U.S. Agriculture Secretary Tom Vilsack joined forces on efforts to aid in this crisis. On Friday, July 22, 2016, in Columbia, Missouri, Senator Claire McCaskill and U.S. Agriculture Secretary Tom Vilsack hosted a town hall discussion on solutions to combat the nation’s opioid epidemic. Vilsack leads the national rural opioid addiction initiative. Kathy Pabst, MAFP executive director, represented your association at this meeting, along with over 100 other interested constituents.

In a press release from Senator McCaskill’s

office, “This is a public health crisis that’s shaken Missouri and communities across the country, and it’s going to take real action from all levels of government, the health community, law enforcement, and educators to turn this epidemic around,” McCaskill said. “That’s why it’s critical the state legislature in Jefferson City get off the sidelines from which they’ve allowed Missouri the distinction of being the only state in the country without a Prescription Drug Monitoring Program—a commonsense tool that’s at work helping 49 other states combat this epidemic.

Secretary Vilsack and I gained some valuable insight from those on the front lines working to make a difference and save lives—as we continue to work in Washington to aid communities as they battle this addiction crisis.”

“Each day we lose 78 lives to opioid overdoses,” Secretary Vilsack said. “For the individuals and 20

MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

their families who are struggling, we cannot allow another day to go by before we act.” Vilsack told the Jefferson City News Tribune (July 20, 2016) that people’s hard work on farms or in manufacturing often leads to back, shoulder and knee problems among others, “so there may be a need for aggressive pain management. That lends itself – and has over the course of the last 15 or 16 years – to more and more prescribing of opioids in rural areas.”

Today’s town hall was part of a series of events across Missouri that McCaskill is hosting as part of her efforts to combat the nation’s opioid epidemic. McCaskill was successful in shaping recent federal legislation to open up resources to local and county Prescription Drug Monitoring Programs (PDMPs). Secretary Vilsack is leading the Administration’s multi-pronged effort focusing on addressing opioid and heroin abuse in rural areas and communities across the country.

The Comprehensive Addiction and Recovery Act (S.524)—federal legislation which provides resources to states to combat the record number of prescription drug and heroin deaths across the country—was approved by the Senate and was signed by the President on July 22 and became Public Law 114-198 on that same day. Local governments in Missouri that are working on county-level PDMPs are eligible to apply for federal resources.

Among Midwestern states, Missouri ranks number one in the rate of prescription opioids sold in the region.

We are dedicated to rural and underserved areas of our great state! MHPPS partners with safety-net providers and health care systems throughout Missouri to help health care professionals, like yourself, find a community that best fits your personal and professional needs. Whether it’s a scenic rural setting, dynamic urban location, or somewhere in between, we are committed to focusing on your interests and careers that count!

Find Out More: Contact Us Today!

Joni Adamson Manager of Recruitment 573.636.4222 jadamson@mo-pca.org www.3rnet.org/missouri

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MHPPS is non-profit and located within the MO Primary Care Association MO-AFP.ORG 21

EXTERNSHIP

An unforgettable externship experience

O

ver the summer, I was selected to participate in a one-month summer externship at Research Family Medicine Residency in Kansas City, MO. It was a true pleasure for me, as a medical student interested in family medicine, to participate in a first-class education provided by the attendings, residents, nurses, and patients at Research Hospital and their associated clinic, Goppert-Trinity Family Care.

"

I know that I will never forget not only the clinical education, but the humanistic education as well."

From the first day, the residents and attendings welcomed me (and my many questions) and allowed me to perform histories and physicals on their patients. They constantly provided me with constructive feedback and pushed me to form as large of a differential as I could. For two weeks, my experience at Goppert-Trinity Family Care, their outpatient clinic, ranged from educating a patient about her blood pressure medication, participating in a cyst excision, and even following a patient from her pre-natal care, delivery, and into her first post-natal office visit. By the end of my time at the clinic, I felt very comfortable interviewing, examining, and forming a treatment plan for patients despite having only one year of medical school under my belt. I also spent a week on the labor and delivery service at Research Hospital where I participated in morning rounds, prepared for inductions, and scrubbed in on a few c-sections. The OBs, residents, and nurses were instrumental in teaching me about fetal heart tracings, the stages of delivery, and the various interventions during labor. Every Monday

22

MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

afternoon, I traveled to Harrisonville, MO to see patients at an OB outreach clinic that assists disadvantaged patients with their pre-natal care.

It was amazing to witness not only the exceptional clinical care that Research provides, but also their awareness of health Jacob Ripp, ATSU-KCOM, disparities here in Missouri.

OMS II I was truly proud to be part of such a great team.

The crown jewel of my externship was a week-long experience on the medicine service (go orange team!). I was paired with an intern, and rounded on one or two of his patients every morning (which, by the way, was more than enough). After rounding, we would meet for table rounds, which was my favorite part of the day. I fell in love with the back-and-forth between the interns, chief resident, pharmacist, and attending as they discussed each problem for every patient on the service. Every night, I would bury myself in UpToDate guidelines, looking up new pathology that I’d never heard of, and exploring treatment options for the patients that I’d seen or heard about during rounds. Eventually, I found the courage to present my own patient and discuss how I would manage each issue. Every day, the team welcomed me as if I were a colleague, which left an unforgettable impression on me.

I want to thank MAFP, the American Academy of Family Physicians Foundation, and the Family Health Foundation of Missouri for allowing me to experience truly phenomenal family medicine.

I still feel incredibly lucky and grateful to have spent a month with such competent and compassionate physicians, and I know that I will never forget not only the clinical education, but the humanistic education as well.

CONGRESS OF DELEGATES

AAFP Congress of Delegates took care of business in Orlando By: David Schneider, MD, MSPH, FAAFP

W

e just returned from the AAFP's Annual Congress of Delegates. This body consists of two representatives from each state chapter plus representatives of underrepresented groups such as international medical graduates and new physicians. The Congress meets in the fall every year to set policy for the AAFP that determines how we practice medicine to make our patients' lives and health better. You are currently represented by Dr. Todd Schaffer and me as your delegates and Drs. Keith Ratcliff and Kate Lichtenberg as your alternate delegates.

The Congress opened up with speeches from our leadership. Dr. Wanda Filer, who completed her presidency gave a heartfelt speech and showed a poignant video by Zdogg to the tune of the hit, "7 Years" (check it out on YouTube). I learned new terms such as WAC (work after clinic).

And our Executive Vice President, Dr. Doug Henley called for healthcare to be designated a basic human right in the United States.

Hot topics this year: • The student pipeline and debt • MACRA - winners vs. losers and payment reform • Over regulation • Opioid epidemic • Family physician burnout • EHRs, WAC, work-life balance, and practice hassles • A new way to phrase the triple aim: better care, better health, smarter spending

Over 60 resolutions were submitted for consideration by this governing body. One of which was crafted by the MAFP to advocate for a national prescription drug monitoring database, and in lieu of that, seamless interoperability of those that are run by the states. Your delegation presented testimony at the hearing along with over 10 physicians testifying in support of the resolution. Although the reference committee recommended a substitute resolution, the delegates overturned that recommendation during the Congress and adopted the resolution with the original language intact. See Dr. Keith Ratcliff’s report on this resolution on page 24.

At the conclusion of the Congress, Dr. Todd Schaffer was introduced as a candidate for the AAFP Board of Directors at the 2017 meeting to be held in San Antonio! All are welcome to join us help get Dr. Schaffer elected.

After the conclusion of the Congress, Dr. Atul Gawande opened up the Annual Family Medicine Experience (what used to be called the Annual Scientific Assembly) with a passionate talk on caring for our patients at the end of life. He suggested that asking, "What's important to you?" to all patients whom you would not be surprised if they died in the next year. He noted that patients at the end of life would die at home in the comfort and presence of their families if we elicited their true beliefs about end of life care.

Todd Shaffer, MD, MBA FAAFP, Delegate

David Schneider, MD, MSPH, FAAFP, Delegate

Keith Ratcliff, MD, FAAFP, Alternate Delegate

Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate

MO-AFP.ORG 23

CONGRESS OF DELEGATES

Missouri resolution passes with unanimous vote at the AAFP COD

R Keith Ratcliff, MD, FAAFP, Alternate Delegate

24

esolution 515 which asked for the creation of a national prescription drug database with mandated interoperability was written and introduced by the MAFP and co-sponsored by the great states of Arkansas, Kansas and Tennessee. This resolution, which asked for the creation of a national prescription drug database with mandated interoperability, was passed unanimously by the AAFP COD with only one minor amendment. But the road to passage of this important shift in focus for the AAFP was not smooth.

Missouri delegate David Schneider, MD, of St. Louis, introduced Resolution 515 to the reference committee hearing and reported that his state (the only one in the nation) does not have a prescription drug monitoring program (PDMP). The Reference Committee on Advocacy considered about 40 minutes of testimony on this issue.

Maryland delegate Adebowale Prest, MD, of Hebron, noted that she recently learned from a patient that the patient successfully opted out of the Maryland PDMP because of options provided under the Health Insurance Portability and Accountability Act. The patient admitted to doctor-shopping for narcotics. Dr. Prest remarked, "I was unaware that opting out was an option for patients."

Louisiana alternate delegate Bryan Picou, MD, of Natchitoches, told the reference committee that his state had a good program but lamented the lack of interoperability. "We don't have access to states next to ours, and we often get calls from another state saying they've got a patient who's walked in with a Louisiana prescription."

Pennsylvania delegate Madalyn Schaefgen, MD, of Allentown, reiterated that patients can opt out -- as can pharmacies. Mail-order pharmacies located outside the state are popular with patients and are not required to participate in the drug databases that currently exist in most states.

Upon witnessing the overwhelming support for our resolution before the reference committee, your Missouri delegation was both astounded and disappointed with the Substitute Resolution 515 that was suggested which read as follows:

MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

RESOLVED, That the American Academy of Family Physicians support that each state have a functional prescription drug monitoring program for clinical purposes that is nationally interoperable, ensures secure data transport between systems and maintains the highest level of patient confidentiality.

Obviously the substitute resolution ignored the main intent of our initial Resolution 515 which was to shift the focus of the AAFP from a state-by-state solution to a national solution for prescription drug monitoring in the face of our unprecedented opioid crisis. It also would have no provisions to protect our Missouri patients, who will not in any near future have the safety of a state sponsored PDMP. As you recall, this has been one of the top priorities for our Advocacy Commission for over 10 years. Despite a very strong coalition of stakeholders including the MAFP, MSMA, MAOPS, and over thirty other organizations, who have spent countless hours in Jefferson City advocating for a solution, we have failed to pass a meaningful PDMP in our state. Given the filibuster rule in our state Senate, which historically has been the tool used to block a vote on the many PDMP bills that we have been involved with over the years; it seems unlikely that Missouri will join the other 49 states that have been successful in passing PDMP legislation.

As the AAFP COD unfolded, we were able to use the rules to extract our resolution from the reference committee report. Dr. Schneider moved that the original Resolution 515 replace the Substitute Resolution 515 suggested by the reference committee. This opened the floor of the COD to debate the issue. One friendly amendment to delete the words “maintain and� from the second resolved was accepted by your delegation.

Dr. Ratcliff gave compelling testimony on the need for a national solution and the need for refocus of our AAFP Advocacy efforts away from a state-by-state program which is inconsistent and not coordinated. Missouri borders eight states, more than any other state in the country, and

CONGRESS OF DELEGATES

for the safety of our patients, a national PDMP is a much more elegant solution. The floor debate was overwhelmingly in support of our initial Resolution 515 with many other state delegations, special constituencies, and the resident /student section testifying on our behalf. The question was called and the entire Congress voted in favor of adopting our initial Resolution (with the mentioned amendment by deletion) rather than accepting the reference committee recommendations. The final resolution as passed follows this article.

We were very proud that our resolution was passed unanimously by the COD, and that we can now look forward to a shift in the focus of our AAFP that will help ensure the safety of all our patients.

The work done by our Executive Director, Kathy Pabst, and your entire delegation was worth it in the end.

RESOLUTION NO. 515 - National Prescription Drug Monitoring Program Introduced by the Missouri, Arkansas, Kansas and Tennessee Chapters Referred to the Reference Committee on Advocacy WHEREAS, Each day, 78 (2014) people die from an overdose of opioids and other prescription drugs in the United States1, and WHEREAS, opioid overdoses have exponentially increased in the last 10 years, and WHEREAS, Missouri has the seventh highest overdose rate in the country2, and WHEREAS, Missouri shares eight border states – the most in the country – and has become a safe haven for doctor shoppers, and WHEREAS, Missouri is the only state3 without a prescription drug monitoring program, and WHEREAS, St. Louis City and County have passed and are implementing local prescription drug monitoring programs and other Missouri communities are actively pursuing the same, and WHEREAS, a prescription drug monitoring program is a critical tool for reducing the abuse, addiction, and diversion of opioids and other prescription drugs4, and WHEREAS, a prescription drug monitoring program supports access to legitimate medical use of controlled substances, and WHEREAS, Missouri legislators, law enforcement, physicians, pharmacists, prevention and substance abuse groups, health care organizations, and citizens have supported the passage of a prescription drug monitoring program since 2007, and

WHEREAS, patient privacy is a critical provision of a successful program, and WHEREAS, prescription drug monitoring programs in other states5 have been shown to reduce abuse, save lives, and protect our communities, and WHEREAS, the American Academy of Family Physicians position paper on “Pain Management and Opioid Abuse: A Public Health Concern”6, urges all states to implement prescription drug monitoring programs and the interstate exchange of registry information as called for under the National All Schedules Prescription Electronic Reporting (NASPER) Act of 2005, now, therefore, be it RESOLVED, That the American Academy of Family Physicians advocate for interoperability between prescription drug monitoring programs that will ensure secure data transport between systems and maintain the utmost highest level of privacy for patients’ history of controlled substance prescriptions, and be it further RESOLVED, That the American Academy of Family Physicians advocate for creating a secure national database for physicians and pharmacists to review information about patients who have been prescribed drugs that have a high potential for being abused or misused, such as opioid agonists, benzodiazepines, sedative hypnotics, amphetamines and similar agents, and cannabinoids.

References: 1. Center for Disease Control, 2014 http://www. cdc.gov/drugoverdose/epidemic/index.html 2. Prescription Drug Abuse: Strategies to Stop the Epidemic, Healthy Americans Website, http:// healthyamericans.org/reports/drugabuse2013/ release.php?stateid=MO 3. Occupational Health and Safety Website, https://ohsonline.com/articles/2012/08/21/ missouri-lone-holdout-on-prescription-drugmonitoring.aspx?admgarea=news 4. US Department of Justice, Drug Enforcement Administration, Office of Diversion Control, http:// www.deadiversion.usdoj.gov/faq/rx_monitor.htm 5. Center for Disease Control State Successes, http://www.cdc.gov/drugoverdose/policy/ successes.html 6. American Academy of Family Physicians Position Paper, http://www.aafp.org/dam/AAFP/ documents/patient_care/pain_management/ opioid-abuse-position-paper.pdf MO-AFP.ORG 25

CATHERINE MOORE, DO

Moore presented with AAFP Award for Excellence in GME

C

atherine Moore, DO was presented with the AAFP Award for Excellence in Graduate Medical Education on Sunday morning at FMX, following Congress of Delegates. This award recognizes outstanding family medicine residents for their leadership, civic involvement, exemplary patient care, and aptitude for and interest in family medicine.

Dr. Moore's performance during residency training ranks her among the top family medicine residents in the country.

Dr. Moore completed her residency at Mercy Family Medicine Residency in St. Louis, Missouri and attended medical school at A.T. Still University at Kirksville College of Osteopathic Medicine in Missouri.

Dr. Moore's performance during residency training ranks her among the top family medicine residents in the country.

Kara Mayes, DO, Catherine Moore, DO and MAFP Executive Director, Kathy Pabst.

26

Catherine Moore, DO and her husband, Jeremy.

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2016

FACTS, NOT FADS

WHERE HEALTH IS PRIMARY. When it comes to nutrition and exercise, there is no shortage of fads. But the facts remain the same: most of what makes us healthy results from the choices we make each day. Patients with a primary care doctor have someone who can provide on-going, personalized, factbased guidance about nutrition and exercise habits—and the support needed to follow it.

Family doctors have improved the health of their patients for generations by focusing on strong, long-term relationships. We believe every patient should have access to sound advice from a trusted source to help make smart choices about health.

Trends are temporary, your health is forever.

Let’s make health primary in America.

Learn more at healthisprimary.org.

Brought to you by America’s Family Physicians

#MakeHealthPrimary

COX FAMILY MEDICINE

2016-2017

COX FAMILY MEDICINE RESIDENCY Third-Year Resident Physicians Meghan E. Blay, DO

D. Wes Campbell, DO

Ian T. Cheyne, MD

Angela L. Conklin, DO, MBA

Brett A. Mossberger, DO

Shawn M. Stranckmeyer, MD Chief Resident

Samantha A. Wallace, DO, MBA Chief Resident

Steven E. Zinter, DO

Aaron R. Buzard, MD, MPH

Blake A. Fulks, MD

Meghan E. Guthrie, MD

Shannon N. Marsden, MD

Caitlin S. Schmitt, DO

Kenneth F. Starnes, III, MD

Lisa S. Trask, DO

Sarah A. Williams, MD

Jennifer C. Bulcock, MD

Matthew D. Dalke, MD

Whitney J. Davis, DO

Alyssa A. Easter, MD

J. Cliff Ganus, MD, MPH

J. Evan Johnson, MD

John P. Long, III, MD

Lukas Mathews, MD

Second-Year Resident Physicians

First-Year Resident Physicians

Jenny M. Eichhorn, MD

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MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

MERCY FAMILY MEDICINE

Mercy Family Medicine 2016-2017 First-Year Resident Physicians

Ann Lottes, MD University of Missouri Columbia School of Medicine

Eric Martin, DO Des Moines University College of Osteopathic Medicine

Kate Rampon, MD University of Tennessee Health Science Center College of Medicine

James Starrett, DO Kansas City University of Medicine and Biosciences

Brittanie Weinhaus, DO AT Still University of Health Sciences Kirksville

Rebecca Winchester, DO Kansas City University of Medicine and Biosciences

Second-Year Resident Physicians

Cherry Cockrell, MD University of Oklahoma College of Medicine

Sally Kurz, MD University of Texas Southwestern Medical Center

Jeremy Oliver, DO Kansas City University of Medicine and Biosciences

Daniel O’Loughlin, DO AT Still University of Health Sciences Kirksville

Brett Warden, DO Kansas City University of Medicine and Biosciences

Mark Zacharjasz, MD Saint Louis University School of Medicine

Mihiret Belihu, MD Gondar College of Medical Sciences

Catherine Moore, DO AT Still University of Health Sciences Kirksville

Third-Year Resident Physicians

Perini Shah, DO University of North Texas Health Science Center

Mallorie Rhymer, MD Saint Louis University School of Medicine

Alex Meyer, DO AT Still University of Health Sciences Kirksville

Alex Mazzaferro, MD Saint Louis University School of Medicine

MO-AFP.ORG 29

SLU FAMILY MEDICINE

SAINT LOUIS UNIVERSITY FAMILY MEDICINE RESIDENCY At SSM Health St. Mary’s Hospital 6420 Clayton Road, Room 2234 St. Louis, MO 63117

Kanika Turner, MD PGY3-Chief Resident

Michelle Hall, MD-PG2

Ritesh Gandhi, MD-PG1

Muhammad Dalal, DO-PG3

Jared Henrichs, MD-PG2

Preethi Schmeidler, MD–PG3

Joseph Moleski, DO-PG2

Britany Goodrich-Braun, MD-PG1

Yibing Li, MD-PG1

Alicia Brooks, MD-PG2

Michael Donovan, MD- PG2

Lauren Waible, DO-PG2

Deanna Chavez, MD-PG1

Alison Matsunaga, MD-PG1

http://familymedicine.slu.edu/residency ERAS Code: 1202831704 NRMP Code: 1365120C1

30

MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

Ashley Meyr, MD-PG1

UMC FAMILY MEDICINE

DEPARTMENT OF FAMILY & COMMUNITY MEDICINE UNIVERSITY OF MISSOURI | SCHOOL OF MEDICINE 2016-2017 HOUSE STAFF Chief Residents

Andrea Schuster, MD SP-Blue

John Ballantyne, MD Fayette

Erin Pearson, MD SP-Gold

Chase Beliles, MD Fulton

Shari Chang, MD SP-Blue

Sarah Kirchhoff, MD Fulton

Katie Martinez, MD SP-Green

Nicholas Bratten, MD SP-Blue

Parker Kohlfeld, MD Fulton

Veronica Sievert, MD Fulton

Megan Warhol, DO Fayette

Third-Year Residents

Christine Wilson, DO SP-Green

Andrea Bickerton, MD Fulton

Asa Chu, MD SP-Green

Carlos Rubio-Reyes, MD Family Health Center

Ben Stevens, MD Fulton

Krystal Foster, MD Family Health Center

Patrick Granneman, DO Fayette

Andrew Hinojosa, MD SP-Green

Becca Hogg, MD Family Health Center

Tim Ratliff, DO SP-Blue

Drew Satterfield, DO Fulton

James Tucker, DO Fayette

Second-Year Residents

Andy Peterson, MD Fulton

First-Year Residents

Chase Ellingsworth, MD SP-Gold

Howard Tseng, MD SP-Blue

Ben Crary, DO Fulton

Geoffrey Dankle, MD Fulton

Brady Fleshman, MD SP-Gold

John Jayroe, MD SP-Green

Kaci Larsen, MD Fayette

Stephanie Lersch, MD Family Health Center

Kaitlin Saucier, MD Fayette

Calvin Tai, MD SP-Blue

Kristen Killen, MD Family Health Center

Aaron Wood, MD Family Health Center

Integrated Residents

Tyler Gouge Fayette

Misty Todd Fulton

MO-AFP.ORG 31

32

MISSOURI FAMILY PHYSICIAN

OCTOBER-DECEMBER 2016

Karina Belino, DO ATSU

Robbie Harriford, MD University of Kansas

Hannah Anderson, MD

University of Kansas

Ryan Carey, DO, MA, MPH

Touro CA

PGY-1 Family Medicine Residents Starting July 1, 2016

ATSU

Andrew Wherley, MD University of Illinois

Josh Buschling, DO Rocky Vista

Adam Legg, DO Kansas City University

Megan Buri, MD Creighton

Benson Lan, MD St. Louis University

Joshua Booth, MD University of Arkansas

Helen Hill, DO, MPH ATSU - SOMA

Chelsie Cain, DO

Phone: 816-404-7752 Fax: 816-404-7756 email: info@umkcfm.org Program Director: todd.shaffer@tmcmed.org

Truman Medical Center Lakewood 7900 Lee's Summit Road Kansas City, MO 64139

University of Missouri-Kansas City Dept. of Community and Family Medicine

UMKC FAMILY MEDICINE

Christopher Chappell, DO

Sourab Chopra, MD

Gaurav Chaturvedi, MD,PhD

Priscilla Borden, MD Gewel

de los Santos, MD

Manveer Flora, MD

Joseph Meier, MD

CLASS OF 2019

Brittney Frisby, MD

Stephen Person, DO

Georgina Green, MD

CLASS 2018

Adam Morawski, MD

Christopher Fotopoulos, DO

Brittani Moeller, DO

Dianne Elledge, DO

Harmandeep Khosa, MD

Ed Christiansen, MD

Casey Gee, MD

Nathan Boehr, DO

Nida Dillon, DO

Faisal Ali, MD

Caleb Baughn, MD

CLASS OF 2017

Will Patton, DO

Anna Hanson, MD

Merlin Sunny, DO

Varsha Pawate, MD

Joanita Idicula, MD

Katelyn Falk, MD

Hazen Short, MD

Kendall Johnson, DO

Benjamin Skoch, DO

Maureen Weber, MD

Robert Kreikemeier, DO

Genna Siemons, MD

2016-2017 R3 CHIEF RESIDENTS

Max Zollicker, MD

Tommel Samani, MD

RESEARCH FAMILY MEDICINE

MO-AFP.ORG 33

Find Your Kind in an AAFP Member Interest Group The AAFP is committed to giving all members a voice within our increasingly diverse organization. Member interest groups (MIGs) have been created as a way to define, recognize, and support AAFP members with shared professional interests. MIGs support members interested in professional and leadership development and provide connections to existing AAFP resources, opportunities to suggest AAFP policy, and networking events with like-minded peers.

Current AAFP MIGs include: • Direct Primary Care • Emergency Medicine/Urgent Care • Global Health • Hospital Medicine • Independent Solo/Small Group Practice • Oral Health • Reproductive Health Care • Rural Health • Single Payer Health Care • Telehealth

Visit aafp.org/mig to learn more, join a MIG, or start your own.

ANNUAL SCIENTIFIC ASSEMBLY

2017

DATE in

THE

E M C N R A E K R O W T NE RELAX

SAVE

2017

JUNE 9-10

THE LODGE AT OLD KINDERHOOK

ANNUAL FALL CONFERENCE

NOVEMBER 10-11

BIG CEDAR LODGE

2017

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

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Count on the AAFP to find out what MACRA means for you and your practice.

Learn more | aafp.org/MACRAReady