Residents and Students: Future Faces of Family Medicine by mo-afp

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician

April-June 2018 Volume 37, Issue 2

RESIDENTS & STUDENTS:

FUTURE FACES OF FAMILY MEDICINE

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executive commission Board Chair - Kathleen Eubanks-Meng, DO (Blue Springs) President - Mark Schabbing, MD (Perryville) President-Elect - Sarah Cole, DO, FAAFP (St. Louis) Vice President - Jamie Ulbrich, MD, FAAFP (Marshall) 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: Emily Doucette, MD (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: Vacant 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 Rosemergy, DO (Kansas City) District 8 Director: John Paulson, DO (Joplin) 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, FAAFP (Cape Girardeau) Director at Large Kurt Bravata, MD (Buffalo) resident directors Alicia Brooks, MD, SLU Ann Lottes, MD, SLU (Alternate) student directors John Heafner, MSPH, SLU MiMi Liu, SLU (Alternate)

MARK YOUR CALENDAR AAFP Annual Chapter Leadership Forum/National Conference of Constituency Leaders April 26-28, 2018 Sheraton at Crown Center, Kansas City, MO

AAFP National Conference of Family Medicine Residents & Students (NCFMRS) August 2-4, 2018 Kansas City Convention Center, Kansas City, MO

Show Me Family Medicine Conference (formerly ASA) June 8-9, 2018 The Lodge at Old Kinderhook, Camdenton, MO

Family Medicine Transition Conference August 17-18, 2018 Double Tree Hotel, Jefferson City, MO

MAFP Board of Directors Meeting June 10, 2018 The Lodge at Old Kinderhook, Camdenton, MO

Annual Fall Conference November 9-10, 2018 Big Cedar Lodge, Ridgedale, MO

INSIDE THIS ISSUE Pg. 4 President's Report 6 Issue Focus: Students and Residents 25 Advocacy Day Recap 27 Member Perspective 31 Register for SMFM 2018 32 Resident Grand Rounds 37 Help Desk Answers 38 Opioids: MAFP/AAFP Collaboration 43 Members in the News 46 MAFP Leadership Meets with MDHSS Director

Advertisements Pg. 5 NORCAL 24 ProAssurance 29 MHPPS 35 Citizen's Memorial 36 KaMMCO 40 Core Content 41 Physicians Standard Insurance 42 ProAssurance 47 MO Beef Industry Council

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 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.

MAFP Annual Business Meeting June 9, 2018

(Creek View Conference Center)

The Lodge at Old Kinderhook, Camdenton, MO

MO-AFP.ORG 3

Continuing the Fight for You and Your Patients

T Mark Schabbing, MD President

his past quarter has been very busy for the MAFP. In January, the Executive Commission met with Randall Williams, MD, FACOG, Director, Missouri Department of Health and Senior Services. This was an exciting meeting with someone who I believe is willing and happy to work with the MAFP. This meeting is outlined in another article in this magazine and would refer you to read it on page 46. In February, our staff earned their keep. Our academy hosted the Annual Multi-State Forum in Dallas, TX. At this conference, several states come together to share and discuss what is happening in their respective states. Leadership discusses the best practices used in each state and what is working or what has not worked well for them. Our leadership was given ample time to workshop and network with the members from the other states. We received updates from Michael Munger, MD, our AAFP President, and Shawn Martin, Senior Vice President of AAFP Advocacy, Practice Advancement and Policy. We were given information on what is going on at the national level and where the AAFP is fighting for us and our patients.

I think it was great that we had medical students and residents from St. Louis University, Mercy, and University of MissouriKansas City, join us and be active in this process."

I would like to take a minute and recap our Advocacy Day in Jefferson City, MO that we hosted on February 19th and 20th. Our board put together an informational meeting that was hosted by Keith Ratcliff, MD, Chair of our Advocacy Committee. We were given a brief account of how the legislative process works and then updated with the recent information about bills that affect us and our patients. Randy Scherr and Brian Bernskoetter, our new lobbyists, joined us for the meeting and our visit to the Capitol.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

Our staff made arrangements for each of us to have time to spend with our respective representatives and senators from our area. I would like to thank all those who joined us on this special day. In addition, I think it was great that we had medical students and residents from St. Louis University, Mercy, and University of Missouri-Kansas City, join us and be active in this process. We will not be slowing down in the next couple of months and we will be changing our direction toward leadership and education. In April, staff and members will be attending the AAFP leadership conference that will be located in Kansas City, MO. Concurrently, the National Conference of Constituency Leaders will hold their annual meeting to identify opportunities for improvement and change within family medicine. The MAFP Show Me Family Medicine Conference (formerly the Annual Scientific Assembly) will be presented again at The Lodge at Old Kinderhook in Camdenton, MO. I hope to see many of you at our Annual Meeting where we can talk about what we are doing for you and your practice or what you would like for us to address better. The MAFP has a strong commitment to our members and this is also extended to the residents and new doctors that join our organization. Last year, we hosted our first Family Medicine Resident and New Physician Transition Conference. This year's conference will be geared toward residents and third and fourth year students. This is a Friday afternoon and Saturday morning conference where we focus on topics related to the challenges of transitioning from a training program to a professional life. We host talks that are specifically meant to answer some of the common questions residents are faced with during this time. Some of the important issues which will be addressed at this conference include contract negotiations, different practice types for family physicians, addressing burnout in residency and private practice, managing time and money in the work place and at home, and time to mingle with recruiters and residency programs. Last year was very successful and I hope to see more young doctors come out and join us for our second Family Medicine Transition Conference.

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STUDENTS and RESIDENTS

Walking alongside my continuity patients through a disease course or a pregnancy is the most rewarding part of being a new physician. Growing the rapport and trust that comes with following through with more of my own panel continues to draw me into family medicine through the busy and stressful parts of residency." Kate Rampon, MD, PGY2

FUTURE FACES OF FAMILY MEDICINE This issue of Missouri Family Physician focuses on residents and students. They are the future of family medicine. The following pages contain information and articles from residents and students sharing their first-hand knowledge they have obtained through the process of medical school and residency. Take a look, and meet some of the future faces of family medicine.

Continuing a Legacy of Service

Alicia Brooks, MD St. Louis University MAFP Resident Director

y name is Alicia Brooks, and I am a third year resident at Saint Louis University’s Family Medicine program. I am a third generation physician, though I did not know I wanted to pursue medicine until my junior year of college. My grandfather was a family physician in a small town in Michigan. He made house calls for $5.00 and did what we now call full scope family practice—delivered babies, rounded in the hospital, cared for the dying etc… My dad set out to be a family doctor when he started medical school, but fell in love with surgery and is still a practicing Trauma Surgeon and Critical Care physician. Despite growing up around medicine, I was more interested in music as a career and even completed a year of undergraduate studies as a music major. Through some personal circumstances, I ended up being broadly interested in healthcare. As a college junior, I was a biology major and traveled to Zimbabwe to volunteer at a mission hospital there for a semester. My experiences there solidified my desire to pursue medicine and the rest is history. I graduated from Quillen College of Medicine at East Tennessee State University in Johnson City, TN in 2015. I had chosen family medicine for many reasons, including my desire for continuity of care, curiosity about every discipline of medicine and interest in community health. I was thrilled to match to Saint Louis University’s Family Medicine Residency. During my training at SLU, I have received education regarding social determinants of health, both formally and through each of my patients at the Federally Qualified Health Center which houses my continuity clinic. I learned to grapple with the factors beyond medicine and beyond the diagnosis that influence my patients’ health and wellbeing. There have been challenging days, when patients without insurance need specialty care but cannot afford it; and I have to learn as much as possible about rheumatologic or endocrine pathology to bridge them as they are working towards access to care. Some patient “problem lists” are overwhelmingly long. As an intern, I remember feeling a lump in my throat as I sought to figure out how to prioritize and care for them. Now as a soon to be graduate, I still pause when I see a

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

Get involved with your local family medicine chapter or the MO-AFP, you’d be surprised how little extra time it takes and how much you can learn from being a part of it."

long list but that feeling of being overwhelmed is gone. I know I have overcome it before and will continue to find creative ways to manage complex chronic comorbidities with the help of my experienced faculty. It has been an honor to be involved in my community as a resident and be able to extend that to the larger community of the State of Missouri’s family physicians. I have had the privilege to serve as the Resident Alternate Director last year and as Resident Director to the MO-AFP Board of Directors this year. I joined the Board’s Advocacy Commission and learned about the process of bills becoming laws and how vigilant we all need to be for our patients and our practice of medicine. There are hundreds of bills that are proposed in each legislative session, and many contain language which would directly or indirectly affect us and our ability to care for patients. The discussions surrounding these bills on the commission were appropriately complex, and I saw the commission always seek to represent the members of the MO-AFP in all their recommendations. Being a part of board meetings has been interesting, as I had not been involved in anything like it in the past. It gave me a perspective for what is going on in the family medicine world beyond my training, and I saw great examples of practicing physicians representing the interests of the larger family medicine community. I’m very excited to join that world when I graduate in June. Being a part of the board and the Academy as a resident has enhanced my outlook on what it means to practice family medicine and be a part of our wonderful community. See the next page for some tips I have prepared for residents!

! U 4 S TIP some tips from Dr. Brooks for residents now that she is nearing the end of her tenure on the board and the end of HER residency:

Get involved with your local family medicine chapter or the MO-AFP. You’d be surprised how little extra time it takes and how much you can learn from being a part of it. Then if you decide you want to stay involved in practice you’ve already had some experiences so it is less overwhelming. There are so many ways to be a part of the MOAFP, even if it is just attending the excellent teaching conferences or presenting a poster. You can be on a board commission (Education, Advocacy, Member Services) without being a member of the board, and these meetings happen around the two yearly conferences so it’s actually very accessible to us as residents!

At least keep in mind that there is a lot going on outside of residency. Even if you don’t end up being a part of it during residency, still keep it in your peripheral vision so you are not totally blindsided by it when you graduate and can be a part of the larger family medicine community.

3. 4.

Try to take time to be with loved ones, get some exercise, be outside and partake of a hobby or two. Life is short and residency feels all-consuming sometimes; but it is possible to take a step back and take a deep breath and enjoy some simple things. We’ve all been burnt out or felt like we could not keep going; look to faculty or seniors you respect for advice on how to regain your passion for this profession and for life outside of medicine. If you’re an intern, hang in there, I promise it gets better. If you’re a second year, enjoy the ride! If you’re a third year like me, congratulations! We made it!

MO-AFP.ORG 9

There is No Better Time Than Now

John Heafner, PGY-4 St. Louis University MAFP Student Director

y name is John Heafner and I am a fourth year medical student at St. Louis University. As I wrote this, I was greatly anticipating my Match Day on March 16th! I matched and will continue at St. Louis University! This was an exciting time for me, because I was in a win-win scenario. I knew that I would be happy and well-trained at any of the residencies where I interviewed, which were all within Illinois,

If I could offer any advice to first and second year students contemplating primary care, and more specifically, family medicine, it would be to seek out mentors early and seek out multiple mentors."

Missouri, and Kansas. As I hurry up and wait for the next step of my life to begin, I would like to reflect on the past three and a half years. I was fortunate when I entered medical school knowing that I wanted to go into primary care. This gave me a very targeted approach to exploring specialty options. Within the first few months of medical school, I sought out mentorship opportunities within primary care. From there, I gained volunteer experience at free clinics and health fairs working with family physicians. If I could offer any advice to first and second year students contemplating primary care, and more specifically family medicine, it would be to seek out mentors early and seek out multiple mentors. Family physicians are an eclectic bunch of individuals who practice in numerous locations (rural, suburban, urban) in various settings (outpatient, inpatient, labor and delivery, emergency rooms, etc.), so the more practicing physicians you can talk to, the more you can learn about the breadth of family medicine. If your program does not have many family doctors then look to the Missouri Academy of Family Physicians (MAFP) and the American Academy of Family Physicians (AAFP) to find mentorship opportunities -- there are numerous. For the past two years, I have enjoyed serving as the student member on the Board of Directors. In

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

this role, I have contributed to board discussions and acted as a voting member. I have also helped to recruit students to attend MAFP conferences and Advocacy Day; as well as promoted externship opportunities and scholarships through the MAFP. Along with attending board meetings, I have worked on the Advocacy Commission where critical discussions are held on how to promote and support patients and family physicians in Missouri; specifically on issues surrounding Prescription Drug Monitoring Programs, scope of practice for mid-level practitioners, cigarette taxes, and motorcycle helmet regulations. If there is any advice I could offer to third and fourth year students, it would be to get involved in family medicine either with your local FMIG, the MAFP, or the AAFP. There are numerous student leadership positions, and many other opportunities to make your voice heard and share your opinions. We are the future and there is no better time to train ourselves to be leaders and start improving our healthcare system. As the complexity of paying for and providing care healthcare continues, family physicians are expected to fill the gaps and ensure a coordinated, team-based approach to care. I encourage all students to get to know more family physicians and to get more involved in the specialty, because there is way more to medicine than our respective four-year curriculums taught us. As I transition into residency this year, I will pass the reins over to the alternate director, Mimi Lui, who is currently a third year at St. Louis University. She is a fantastic resource for any and all students interested in getting more involved in family medicine. I will continue to be actively engaged in the world of family medicine and I look

We are the future and there is no better time to train ourselves to be leaders and start improving our healthcare system."

forward to meeting and working with many of you in my future. I appreciate the guidance and look forward to applying the advice that many within the MAFP have provided me over the past two years. Thank you for this opportunity to serve on the MAFP Board of Directors.

AUGUST 17-18, 2018 Jefferson City, Missouri

Are you ready for the next step in your career, whether a third or fourth year medical student or resident? Years of planning and education have brought you to where you are today as you transition to practice as a Missouri family physician. This Missouri Academy of Family Physicians' Transition conference will provide resources and practical tools to Missouri family medicine residents and students as you begin your careers after residency. Participants will experience a welcoming environment to exchange information and ideas with fellow residents, students, and physicians during this two-day interactive conference.

What will you learn?

• Leadership skills essential to performing well in your role • Resources as well as valuable peer and family medicine expert connections • The power of engagement at the community, state, and national levels • Balancing school, work, and family to prevent burnout

Visit mo-afp.org/cme-events to view the schedule and to register.

q&a

Is a Fellowship in Your Future?

Daniel O'Loughlin, DO, MPH

arah Cole, DO, FAAFP, Residency Program Director at Mercy, St. Louis, MO, sat down for a little Q&A with one of her residents, Daniel O'Loughlin, DO, MPH, who will be entereing a Primary Care Sports Medicine fellowship through Utah Valley Regional Medical Center upon graduation in June. See what he has to say about a postresidency fellowship, and why he chose to go that route, how he prepared himself, and his advice to residents interested in a fellowship.

When did you become interested in a postresidency fellowship? Why?

Sarah Cole, DO, FAAFP Residency Program Director Mercy, St. Louis, MO

My interest actually originated along with my interest in family medicine. Throughout medical school I knew that I had a passion for orthopedics, but always felt that if I chose that specialty I’d be missing out on so much of medicine that I loved, which was caring for the “whole person.” When I learned later in medical school that through specializing in family medicine I could not only continue practicing general medicine, but also place an emphasis on sports medicine, which includes non-operative orthopedics, I knew that was the right career path for me.

How did you prepare yourself in residency for fellowship?

I made contact with individuals involved in sports medicine in the area and informed them of my interest, and that I was willing, amidst my busy residency schedule, to volunteer my time in their clinics or with any sports coverage. Through those contacts I was given opportunities to do sports physicals, provide medical coverage for high school and semi-professional sports, as well as with mass participation events; I even made contact with a physician in another state and was able to help cover an Ironman race. I also kept up with current sports medicine literature and got involved in submitting research, case studies, and curriculums in the topics of sports medicine. 12

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

Do all you can to strengthen your resume to become a competitive applicant." - Daniel O'Loughlin, DO, MPH

How did you find and evaluate possible fellowship programs?

There are a lot of great programs out there, so I started by looking at programs located in areas where I wanted to eventually practice, then researched the various aspects of each program to see if training there would prepare me to reach my future practice goals. I found that a fellowship program’s website can be a helpful resource to find out information about that program; however, the best information about programs actually comes from former and current fellows, as well as seeing the program in person. After gathering as much information as I could, I made a spreadsheet that included each of my top program choices and how strong they performed in areas that were important to me. In the end, this helped me form my rank list and decide which program was the best fit for me.

What were interviews for fellowship like?

Interviews were a lot like residency interviews, just with questions focused on sports medicine. Everyone was kind and welcoming, and simply seemed interested in finding out if I would be a good fit for their program.

What advice do you have for family medicine residents interested in fellowship after graduation?

Find out if you are passionate about a certain area in which family medicine offers a fellowship, and whether that passion is enough to carry you through an additional year of training prior to starting your practice. If that is the case, do all you can to strengthen your resume to become a competitive applicant.

Responses to Medical Students' Frequently Asked Questions About Family Medicine

his article provides answers to many of the common questions that medical students ask about the specialty of family medicine. It describes the crucial role that family physicians have in the evolving health care environment, the scope of practice, the diverse career opportunities available, the education and training of family physicians, the economic realities of a career in family medicine, why the future is so bright for family medicine, and why family physicians are passionate about their work.

Family physicians are personal doctors for patients of all ages and health conditions. Now more than ever, they have an essential role in the transformation of the U.S. health care system. Medical students often have questions about the specialty of family medicine. This article provides answers to many of those questions. There are more family physicians than there are physicians in any other specialty. (Although there are more internists than family physicians, they practice in various subspecialties, all with fewer numbers of physicians.) Family medicine has more residency programs than internal

continued on page 14 MO-AFP.ORG 13

Authors: STANLEY M. KOZAKOWSKI, MD, FAAFP, is the director of medical education at the AAFP in Leawood, Kan. KIMBERLY BECHER, MD, is an assistant professor of family medicine at the Joan C. Edwards School of Medicine at Marshall University, Huntington, W. Va. TATE HINKLE, MD, is a second-year family medicine resident at the University of Alabama at Birmingham Huntsville Family Medicine Residency Program and a former student director of the AAFP Board of Directors. REID BLACKWELDER, MD, FAAFP, is a former president of the AAFP and a professor of family medicine at the East Tennessee State University Quillen College of Medicine, Johnson City. CLIFTON KNIGHT, JR., MD, FAAFP, is senior vice president for education at the AAFP and an assistant professor of family medicine at Marian University College of Osteopathic Medicine, Indianapolis, Ind. ASHLEY BENTLEY, MBA, is the student interest strategist at the AAFP. PERRY A. PUGNO, MD, MPH, FAAFP, is a former vice president for medical education at the AAFP. Address correspondence to Stanley M. Kozakowski, MD, FAAFP, American Academy of Family Physicians, P.O. Box 11210, Shawnee Mission, KS 66207-1210 (e-mail: skozakowski@aafp.org). Reprints are not available from the authors. Author disclosure: No relevant financial affiliations. For references, please visit: https://www.aafp.org/ afp/2016/0201/od1.html "Reproduced with permission from Responses to Medical Students' Frequently Asked Questions About Family Medicine, February 1, 2016, Vol 93, No 3, issue of American Family Physician Copyright © 2016 American Academy of Family Physicians. All Rights Reserved." 14

medicine, although it is second in the number of residents. Family physicians make up 13% of the physician workforce, but provide more than 25% of ambulatory care in the United States and more office visits than any other specialty.1 In addition, family physicians deliver many secondary and tertiary health care services, ranging from care of special populations (e.g., those with human immunodeficiency virus infection) to intensive care.

Why Is Family Medicine Such an Important Specialty?

Of all of the medical specialties, family medicine best meets the definition of primary care: first-contact, continuous, comprehensive, and coordinated care to populations undifferentiated by sex, disease, or organ system.2 Health care systems with a primary care foundation have better quality of care, better population health, greater equity, and lower cost.3 The United States has not traditionally emphasized a strong primary care workforce and has not fared well compared with other Western nations in many important measures of health system performance. As the U.S. health system moves to paying for quality rather than quantity of services provided, family medicine is poised to make a substantial positive impact on the health of the nation.

What Are the Family Medicine Model of Care and the Patient-Centered Medical Home? Family physicians are dedicated to treating the whole person. They provide easily accessible care that includes a comprehensive range of services within the context of a continuing relationship. Even when patients require care beyond the scope of family medicine, family physicians maintain responsibility for their patients by coordinating the care provided by other health care professionals. This model of care has been referred to as the patient-centered medical home (PCMH). In an increasingly complex and fragmented health system, the PCMH is a deviation from traditional models of care. It is truly person-centered vs. physician-centered. There is no single model of the PCMH, nor is it defined as existing within a single practice or building. The format is best determined by the community's needs. It is recognized that a team-based approach to care, reducing barriers to care through improved communication and

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

expanded office hours, implementing advanced information systems such as electronic health records, focusing on quality and safety, and providing patient care in the context of family and community, helps to achieve the quadruple aim of better health, better health care, lower cost of care per capita, and improved work life for physicians.4,5 There is a growing recognition that a sustainable health care system will require the integration of primary care, behavioral and mental health, and public health. Some PCMH practices are already expanding the traditional model to incorporate mental health and population health tools.6 As PCMH models evolve, family physicians will continue to strive to provide the right care, at the right time, in the right place, in a manner that best meets their patients' needs.

What Is the Scope of Practice and What Career Opportunities Will Be Available to Me?

As a family physician, you will be uniquely trained to provide comprehensive care for acute and chronic conditions, provide wellness care and disease prevention, perform a variety of procedures, and manage care through collaboration with other specialties. The combination of the broad scope of training, patient-centered care in the context of families and communities, and an understanding of how health systems work will allow you to adapt to any location and setting. For this reason, family physicians have been referred to as “pluripotent stem cells.” Most family physicians are in clinical practice and provide care in ambulatory settings and hospitals. These settings afford a variety of educational and research career opportunities. Teaching is important to family physicians; many regularly train students or residents in their clinical practices. Others choose careers in academic settings such as residency programs or large academic health centers. Some family physicians are research scientists, whereas others participate in practice-based research by contributing data to answer important research questions. The range of career options within family medicine is broad and includes geriatrics, adolescent medicine, hospice and palliative care, pain medicine, sleep medicine, emergency medicine and urgent care, hospitalist medicine, sports medicine, public health, international

medicine, and wilderness medicine. A brief video summarizing the opportunities available to family physicians is available at https://vimeo. com/25152825.

Will Training in Family Medicine Prepare Me to Practice Global Health?

What Types of Combined Residencies or Advanced Fellowship Training Are Available to Family Medicine Residents Who Wish to Pursue a Specialized Interest? The goal of family medicine education is to produce an optimally trained workforce to deliver primary care to patients, families, and communities. Family physicians have unique interests and some pursue a degree of focus within or in addition to their generalist training. As a resident, you may wish to combine your requirements with electives in an area of concentration.9 You may wish to gain in-depth experience in a particular area by participating in a combined residency program, or you may choose to pursue fellowship training after you graduate (Table 1). Table 1.

Optimal health is a fundamental human right that extends beyond national borders and is best achieved with access to primary care.7 Despite headline-grabbing news of outbreaks of diseases such as Ebola, the burden of disease in developed and developing countries has evolved from infectious diseases to chronic illness. Welltrained family physicians with skills in childhood, adolescent, adult, and obstetric medicine and a broad set of procedural skills are well suited to practice in all settings across the globe. This same skill set can be applied within the United States to the care of immigrants and refugees.

What Do I Need to Know About Family Medicine Training?

The aim of family medicine residency training is to prepare graduates to provide comprehensive, continuous care for patients of all ages. A critical part of this education is learning how to access the best evidence at the point of care, to manage and apply information, and to use resources efficiently. Most family medicine residency programs are three years in duration, as are internal medicine and pediatric residencies. Graduates of family medicine programs are well equipped for clinical practice. A few family medicine residency programs are participating in a long-term national pilot program to examine the optimal length of training.8 These programs are four years in duration and offer special tracks or advanced degrees.

Select Fellowships for Family Medicine Graduates • Adolescent medicine* • Behavioral medicine • Clinical informatics* • Community medicine • Emergency medicine • Faculty development • Geriatrics* • Health policy • Hospice/palliative care* • Hospitalist medicine • Human immunodeficiency virus/AIDS care • Integrative medicine • International health • Maternity care/obstetrics • Pain management* • Preventive medicine • Research • Rural medicine • Sleep medicine* • Sports medicine* • Substance abuse • Urgent care • Women's health *—Fellowships accredited by the Accreditation Council on Graduate Medical Education.

Combined residency training programs are hybrids that combine elements of two different specialty programs. They do not constitute a separate specialty, but are designed to lead to board certification in both specialties. There are currently four types of dual-degree residency

continued on page 16 MO-AFP.ORG 15

programs for family medicine: family medicine/ psychiatry; family medicine/emergency medicine; family medicine/internal medicine; and family medicine/preventive medicine. These combined training programs are generally four to five years in duration. Internal medicine/pediatrics programs differ from family medicine. These programs combine internal medicine and pediatrics into a single fouryear residency. According to a recent review, most internal medicine/pediatrics programs do not require training to deliver maternity, gynecologic, surgical, dermatologic, or musculoskeletal care.10 Approximately one-third of internal medicine/ pediatrics graduates subspecialize, rather than practice primary care. A 2013 American Academy of Family Physicians (AAFP) survey of graduating family medicine residents shows that approximately 14% plan to pursue advanced training, including fellowships or advanced degrees. The AAFP is often asked why there are fellowships in some areas and not others. The answer is complex. There are two categories of fellowships based on whether they are accredited by the Accreditation Council on Graduate Medical Education (ACGME) and eligible for specialty certification through the American Board of Medical Specialties (ABMS). The ABMS has 24 primary specialty boards granting certification (e.g., internal medicine, pediatrics, family medicine, surgery). In circumstances where another primary specialty certifying board exists, the ACGME will not accredit a fellowship in that field, and the ABMS will not grant specialty certification. This is why there are no family medicine fellowships in pediatrics. ACGME-accredited fellowships may exist when multiple primary specialty boards offer certification that could be used as the foundation of subspecialty training. One example is adolescent medicine, in which training in pediatrics or family medicine provides the foundation needed for subspecialization in adolescent medicine. Fellows in programs accredited by the ACGME are subject to similar supervisory, evaluation, and work hour requirements as residents. Most U.S. fellowships are not accredited by the ACGME. They can vary in curriculum, duration, and resources. An important distinction regarding nonaccredited fellowships is that fellows in these programs may function as junior faculty. Maternity care is one example of a nonaccredited fellowship. These fellowships may vary in length (one month to two years) and scope (operative maternity care or other procedural training). 16

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

The AAFP maintains a fellowship directory that illustrates the breadth of postgraduate experiences for family medicine graduates (https://nf.aafp.org/Directories/Fellowship/ Search). Some residency programs incorporate advanced degree programs into residency training, such as a Master of Business Administration or a Master of Public Health.

What Types of Procedures Do Family Physicians Perform?

As a family physician, you may perform a variety of procedures (Table 2).11 The frequency ranges from approximately 7.5% for cardiac stress testing and 9.9% for deliveries to 64% for musculoskeletal procedures and 79% for dermatologic procedures.12 Family physicians who provide a more comprehensive scope of practice have greater success at achieving the quadruple aim of health care. Table 2.

Select Procedures in Family Medicine • Anesthesia Conscious sedation Digital, local, and peripheral nerve blocks • Gastrointestinal and colorectal procedures Anoscopy Colonoscopy Enteral feeding tube placement Excision of thrombosed hemorrhoid Flexible sigmoidoscopy Incision and drainage of perirectal abscess Nasogastric tube placement • Genitourinary procedures Newborn circumcision Suprapubic aspiration Urine microscopy Vasectomy • Life support Advanced Cardiovascular Life Support Advanced Life Support in Obstetrics Advanced Trauma Life Support Neonatal Resuscitation Program Pediatric Advanced Life Support • Maternity care Spontaneous vaginal delivery, including fetal monitoring, labor induction/augmentation, and laceration repair Vacuum-assisted vaginal delivery • Musculoskeletal procedures Initial management of simple fractures Injection/aspiration of joints, bursa, trigger points, and ganglion cysts Reduction of shoulder dislocations Upper- and lower-extremity casting

• Pulmonary care Office spirometry • Skin procedures Biopsy Cryosurgery Electrosurgery Incision and drainage Laceration repair • Ultrasonography Basic maternity ultrasonography Musculoskeletal ultrasonography Ultrasound guidance for central vascular access, paracentesis, and thoracentesis • Urgent care and hospital procedures Anterior nasal packing for epistaxis Fluorescein eye examination Foreign body removal Lumbar puncture Peripheral venous access • Women's health care Cervical cryotherapy Colposcopy Endometrial biopsy Intrauterine device insertion/removal Papanicolaou smear Uterine aspiration/dilation and curettage Vulvar biopsy Adapted with permission from Kelly BF, Sicilia JM, Forman S, Ellert W, Nothnagle M. Advanced procedural training in family medicine: a group consensus statement. Fam Med. 2009;41(6):401.

How Do I Know if Family Medicine Is Right for Me?

The best way to know if family medicine is the right fit for you is to work with family physicians in action, by doing a rotation with a family physician in practice. Family medicine is right for different people for different reasons. As you speak with family physicians, you will hear different themes about what they love about their jobs. Some develop deep, meaningful, and continuous relationships with their patients and communities. Some love the ability to practice a broad scope of medicine from birth until death, regardless of condition or disease. Others enjoy the comprehensive training that allows for diverse practice options and that can be adapted to the community they serve.13 Others are drawn to family medicine because of the ability to tackle almost anything, whether at home or abroad. For some, it is the ability to care for the entire family, including managing deliveries and prenatal care. Family medicine is broad in scope, so if you enjoy all of your clerkship rotations and are

having trouble choosing just one field, then family medicine may be your home. Try to recall what inspired you to want to become a doctor. Then imagine where and what your ideal practice would be, and explore residency options that would allow you to create it.

What Factors Should I Consider When Choosing a Family Medicine Program?

Although there may or may not be a perfect program, there are probably multiple programs that would be a good fit for you. Program location is often cited by students as one of the most important factors to consider. Proximity to family, needs of a significant other, the lifestyle associated with a community, and patient populations served by the residency can be elements that differentiate programs. More than one-half of family medicine residents will eventually practice in a community within 100 miles of their residency training.14 The institutional context of the residency within a university/academic health center, community hospital, or community health center and the presence of residents or fellows in other disciplines may be important factors for you to consider. In contrast with other specialty residencies, which are typically based in large academic health centers, many family medicine residencies may be located at smaller community hospitals or community health centers. Most likely, as a student you are being trained in a university or large academic medical center environment where there are many residents and fellows training in a variety of specialties. For residency training, you may prefer an academic environment where there are residents and fellows from other specialties training side by side, with a variety of unusual cases and an abundance of resources. A smaller community hospital or community health center with less competition for patients and procedures, and more focus on common conditions may be a better fit. These descriptions represent broad stereotypes, and there is significant variability within these categories. You will need to choose the best learning environment for you.

How Do Family Physicians Keep Current with Medical Advances Across the Breadth of the Specialty?

All physicians, regardless of specialty, have an obligation to provide the best care possible for their patients. You may worry that family medicine is too broad of a specialty and that you cannot

continued on page 18 MO-AFP.ORG 17

possibly learn everything you need to know. Nothing can be further from the truth. Family medicine residencies give you the core skills to manage most patient concerns comfortably, acknowledge your limitations, use your resources, and give you lifelong learning skills that allow you to grow and evolve with your patients and interests. As medicine advances, it is important to be aware of the most current and the best medical evidence. Family physicians have multiple resources that can be matched to your preferred learning style. These include live and recorded courses; monographs; audio podcasts, such as the American Family Physician podcast; and journals, such as American Family Physician. The use of medical apps has exploded in the past few years; these offer continuing medical education opportunities as well as bedside tools.

What Are the Economic Realities of Medical Education and a Career in Family Medicine?

Medical education is expensive, and nearly all medical students incur significant debt over the duration of their training. The Association of American Medical Colleges reported in October 2014 that the median level of debt is $180,000.15 Family physician salaries support a comfortable lifestyle that allows family physicians to repay their debt through careful planning and a variety of loan repayment options.16 More than one-third of medical students plan to enter a loan forgiveness or loan repayment program.15 These programs typically require residency graduates to practice in an underserved community in exchange for loan forgiveness while earning a salary and benefits like other practicing physicians. Family physicians have been the most recruited specialists since 2006, with an average starting salary of $198,000.17 As the demand for family physicians grows, so do salaries. One large integrated health system in southern California recently increased the starting salaries of family physicians to $250,000. Average family physician salaries are among the top 6% of all U.S. household incomes.18

How Does Family Medicine Training Prepare Me to Be a Leader in Health Care? The breadth of training in family medicine, as well as the emphasis on systems-based practice, makes family physicians natural leaders who are highly sought after to lead health care teams. Patients, communities, and health care systems 18

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

need clinically trained leaders with an intimate understanding of the complexities involved in providing a combination of preventive, acute, and chronic care services. Family physicians work with other physicians, health care professionals, and health care supporters across the realm of specialties, giving them a big-picture view of health care delivery. There are many opportunities to get involved and develop your leadership skills within your local and state chapters of the AAFP.19

Why Is the Future of Family Medicine So Bright? There is growing public recognition that comprehensive primary care is the solution for the health of our communities and the nation to improve health, reduce health disparities, improve health care quality, and lower the cost of care. Around the world, primary care–based health systems have lower costs, higher quality, and better access to care.20,21 The Josiah Macy Jr. Foundation, the Council on Graduate Medical Education, and other respected organizations and policymakers have identified the need to train more primary care physicians.22,23 The Patient Protection and Affordable Care Act contains several key provisions to strengthen primary care. These include enhancing payments to primary care physicians and fostering the creation of advanced primary care models of care.24 A new payment system that rewards outcomes and quality over volume of services provided is being ushered in after the passage of landmark legislation in April 2015.25 Rapid change in the U.S. health care system is increasing demand for family physicians. It is estimated that an additional 52,000 primary care physicians will be needed by 2025.26 Therefore, it is not surprising that family medicine has the highest recruitment rate of any specialty.17 The Family Medicine for America's Health project, which was launched in 2014, creates a roadmap to improve practice models, payment, technology, workforce, education, and research.27 It aims to collaborate with patients, employers, payers, policymakers, and other primary care professionals to show the value and benefits of primary care, and the contribution that family physicians make to meet the health and health care needs of persons throughout the United States. Family physicians make a difference in the health and well-being of others through longterm relationships, mixing the art and science of medicine. That is why they love their work and why the future is so bright for those who choose a career in family medicine.

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MO-AFP.ORG 19

The Art and Practice of Resilience

Remember that you are not alone in this. Talk to someone. Don’t be afraid it will make you seem weak. It won’t. I promise." - Amelia Frank, MD

Amelia Frank, MD University of MissouriColumbia

here is a lot of buzz right now on burnout – in fact, it is probably the buzziest buzzword you can find in the medical literature these days. It seems you cannot open a journal or email without a headline intoning the imminent doom of the art and practice of medicine without combatting the burnout problem. But the problem is that there is no consensus on how to do that: no one has quite figured out yet how to actually fix burnout. Of course, to solve this problem one must first discover when burnout actually begins. Although burnout can begin at different times for different people, some of the highest rates of burnout in medicine are among medical students and residents. Rates of burnout for these groups are almost double that of practicing physicians (taking into account the averages for each specialty) and one study noted that nearly 100% of medical students had experienced burnout at some point or another. Knowing that medical students and residents are already burned out by the time they start practice, leads many people to start throwing out a lot of different ideas on “fixing” this issue. Do we fix this with personal interventions? Systematic changes? Are these interventions and changes simply “bandaids” that don’t cure the problem? If so, where does the cure come from? For practicing physicians there has been a lot of discussion about ideal clinics and systems where lofty goals like “autonomy,” “flexibility,” “joy,”

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

and “mastery,” are foci for physician burnout prevention. The issue with this for medical trainees is most of them can’t experience those ideals on a day-to-day basis. Trainees are just that – in training; instead of mastery they have inexperience and confusion. Instead of joy, many of them experience fear, or threats, or concerns for retaliation. And because of regulations and rules put in place by various educational governing bodies (of which many are very reasonable and necessary) few residents and medical students get to choose their curriculum, or the schedule they keep, or feel like they aren’t the bottom rung of a very tall ladder. So how do we address trainee burnout when the keywords of physician burnout prevention can’t be applied? This leads us to resilience. Resilience is the idea that someone for various reasons has the ability to “bounce back” from stress. This is not to suggest they are impervious to it, but that they can absorb it and still maintain their shape, their character. Many people find this a frustrating topic when discussing burnout because it implies that the solution to what is clearly more than just a personal, individual problem, must come from within that person, that individual, and many find this not only intellectually dishonest but sometimes downright destructive. These concerns have merit. But teaching skills to aid in resilience may help engage students with a variety of supports set

Just breathe."

in place, from familial to financial, from emotional to physical, to keep them propped up when burnout threatens to bring them down. Supporting resilience does not need to imply that that burnout is a personal problem. Supporting resilience does not also inherently imply that you believe burnout is a weakness or that you don’t want to affect further change. Supporting resilience is supporting people. To do so, below is a list of possible resilience tips. These may not all be the kind you usually find in the medical literature – these are hopefully more practical tips, from someone who has lived it and is living it: • Remember that you are not alone in this. Talk to someone. Don’t be afraid it will make you seem weak. It won’t. I promise. • Have at least one great friend who will kill a spider you woke up to when you were napping in your favorite study spot. Have that kind of support. • Go on dates. Have a crush or fall in love – or fall in love all over again with your significant other. Don’t put your life on hold for “after medical school” or “after residency.” Life is too important to put on hold and yes, sometimes you are too tired or frazzled, but it’s good to use your heart instead of your head. • Stay home and feel zero percent guilty about it. It is important to allow yourself time to recharge. Play video games or eat brownies in your sweatpants or read in bed for a full day. Although life is important and it becomes hard to not “use every minute” of free time, totally vegging out is an important aspect of free time, because it allows you the chance to re-center yourself. • Watch movies. See above. • Read books. See above. • Go on great vacations. This doesn’t mean you have to go to the more exotic locales, although you can. It just means take advantage of your vacation – go somewhere new or somewhere familiar or just go home. But don’t work in the lab doing research on your vacation. Vacations become more and more precious as you get further along in school and in your working life, so try not to use it to get to the next place – soon you will be there and wishing you had taken vacation. • Try something new every once in a while – or even more often than that. People generally get into medicine because they love to learn (at least in part); but then we spend all of our time learning millions of bits of information of the same variety. It helps to stimulate your brain in a totally new way every now

and then, even if it’s just for one afternoon. Learn a new hobby, do it for a few weeks, and then stop if you want. Or pick up a new language or instrument. Join an intermural sports team for a new sport. It is exciting for our brains to learn something new, and helps them be more rejuvenated to get back to Harrison’s. • If you are going to live in an apartment, get one with an in-unit washer/dryer. No joke. Your laundry at 3 am will thank me. • Sleep. • Support your friends the same way they support you. Bring your friends dinner when they are on call at night. Being able to help a friend makes you feel great – it is gratitude and giving all at once. Plus, they may then return the favor on a night when you really need a slice of pizza. And, maybe they’ll have a few minutes to eat dinner with you, which can make you both feel better on the tail end of a long day. • Learn to cook. Not a lot. Just a few, easy meals that you always have the ingredients on hand for, so you don’t always have to rely on take-out and frozen meals. While you are at it, eat a fresh vegetable every once in a while. • Put together a presentation or a poster for a conference because the subject is interesting, or the research really excites you – or because the conference is in a great location and you think someone might pay for you to go. Please don’t just do research or put together a presentation or poster because it’s good for a CV. People can tell when you are truly enthusiastic about a subject, and it looks a lot better. • Go on walks on nice days and study while you walk. Or don’t. Just listen to the birdsong. Or gossip with a friend. Get outdoors when you can. • Use your body. Exercise. Get stronger. It feels good for your psyche. • Sleep some more. • Talk on the phone to real people with whom you have a real connection and don’t waste your time talking on the phone to those you don’t. • Pet a dog. Or a cat. Or both. Or enjoy watching a goldfish or cuddle a guinea pig or watch videos of spiders spinning webs on YouTube. Have a connection with an animal that brings you joy – it requires nothing from either of you and gives you so much. • Recognize moments of joy. • Recognize really terrible moments and enjoy leaving them behind. • Enjoy walking out of the hospital or clinic or wherever your practice is in the pink dawn of a warm spring day or the crystal brilliance of a winter evening, and listen to the birds, and just breathe. MO-AFP.ORG 21

The Story of a Resident's Journey to the Show Me State

Cody Stark Rogers, MD Cox Health, Springfield, MO

question I have gotten often in the past four weeks... But really, I have been asked that since the Friday before Christmas when I found out my residency program in Memphis, Resurrection Health, was shutting down. And honestly, it is still a question I have a difficult time answering. Not on the surface though. It's rather easy to say "Oh, funding." But a more complete answer involves explaining why I chose to go to that residency, explaining what we did there that was unique, and explaining all the feelings that surfaced when we found out that we were having to close our doors. And the feelings that followed when we realized that we would not spend the next three years together in training and ministry. I won’t try and bore you with what I understand to be the details; but to put it shortly, the government’s decision to delay increasing the THC funding coincided with some financial straits of Resurrection Residency. And now there are fewer clinics and primary care providers in Memphis, TN as well as 25 residents that were effectively forced to scramble to the four corners of the U.S. Some went to Tulsa, some to Detroit (they were heading there after graduation anyway), some down to Birmingham, and to a myriad of other places. For me, however, things took an unexpected turn. After a surprising message from a friend, my sights were steered to Springfield, MO. Rewinding a bit, when the providers and residents were called into the meeting to announce the closure, I had just come off working all night on the labor and delivery hall. I was pretty tired -- so the news didn’t hit me fully when it was announced. I went home, got a couple hours of sleep, then headed to my parents for a few days of vacation over Christmas. I could have frantically started contacting programs for spots, but I decided to put off further work until my holiday break was over. However, when I started to really think about the implications of not having a job for the next six months and the possibility of redoing the Match, I started to contact people. I typed up emails basically asking in desperation if I could interview late, after re-applying to the Match, and planned to send them to residencies at which I had interviewed and would be glad to train. However, before those emails could be

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

What Happened?

finalized and sent, I received a text message from a friend with whom I graduated medical school and had gone to church.

The whole time I was made to feel a part, not at all an outsider. I laughed so hard my face hurt, met all the spouses and kids of our class, and just had a really good time."

“Hey, did your program close down? We have an open spot.” As you might imagine, I was pretty blown away. This text was coming from Brian Kennedy, an intern at Cox Family Medicine Residency. Cox was one of the programs to which I had a typed email waiting in the wings to be sent. Later that evening I called Brian and we chatted. He gave me an update on the situation and spewed innumerable good things about Cox. I sat down to my computer and changed the email I was planning to send to Dr. Griffin. I was still on nights when I came back from Christmas, so the next few days had some phone tag; but eventually the spot was offered and I accepted. This was an absolute God-send. A program I respected and thought well of had an open first year spot -- and were willing to bring me on without a break in training. The boundary lines, for me, had fallen in pleasant places. The transition was a whirlwind. I finished the busy OB rotation in Memphis on a Thursday, packed my things, and moved to Springfield on Sunday -- after spending a night near Little Rock with my parents. Brian and his family had been exceedingly gracious and let me stay in their extra room. While waiting on my license for Missouri to come in I have been oriented to Cox, met all the residents and faculty, and had been studying for boards. As you might imagine again, the transition has not been easy, but everyone here has been exceedingly warm. Multiple invites to stay with people, multiple invites to churches, constant cordiality, and lots of empathy and advice. The intern class had an event called “Solstice”

"I finished the Busy OB rotation in Memphis on a Thursday, packed my things, and moved to Springfield on Sunday."

recently, which is a time set aside by the residency for bonding within the class. The whole time I was made to feel a part, not at all an outsider. I laughed so hard my face hurt, met all the spouses and kids of our class, and just had a really good time. With the leaving of any place there is sadness. I grieve the loss of what could have been had Resurrection remained: deeper relationships with those residents, continued care for the inner-city impoverished of Memphis, growth of my house church. However, the transfer to Cox was a providential open door and I look forward to the deeper relationships I will have here and the training that Cox will provide. In closing, I leave you with two quotes from my current comrades: “You’re not in Memphis anymore.” “Welcome to Cox.”

National Conference of Family Medicine Residents and Medical Students August 2 - 4, 2018 • KC Convention Center • Kansas City, MO

PICTURE YO

URSELF

in family med

icine

Visit aafp.org MO-AFP.ORG 23

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9/12/17 9:22

Advocacy Day: Missouri Moves Forward

amily physicians were well represented at this year’s Advocacy Day, February 20, at the Missouri Capitol. Keith Ratcliff, MD, Advocacy Commission Co-Chair, provided guidance on the development of the event’s activities and legislative topics. Over 30 visits were made with our Senators and Representatives that hit on key MAFP issues. You can see the list of these issues below. Monday evening’s meeting provided a thorough look and discussion on the priority issues for this year’s session including independent practice of advanced practice registered nurses, increased scope of practice of assistant physicians, and the always recurring, prescription drug monitoring program. Alicia Brooks, MD, Resident, attended both Monday evening and Tuesday’s events and stated that the discussion “was helpful and interesting -- helped me to understand the issues in more depth.”

The rain didn’t stop us from visiting our elected leaders in their offices or outside the chambers. The attendees reported back that their conversations helped the MAFP identify legislators who are supportive of our legislative agenda and those we need to work with to better understand the direct impact of proposed bills. The day wrapped up with a board meeting, the selection of a date for the next MAFP strategic planning session, review of the resident and student August meeting agenda, identified MAFP representatives for this year’s AAFP Family Medicine Advocacy Summit, and solicitation of suggestions for resolutions to submit for the AAFP Congress of Delegates. Other reports were given that ensured the Academy is moving forward, represented at the table on various issues, and financially sound to support our efforts.

2018 PRIORITY LEGISLATIVE ISSUES MAFP SUPPORTS COLLABORATIVE PRACTICE WITH OUR APRN COLLEAGUES OPPOSE HB 1502, HB 1574, HB 1773, SB 646, SB 745 • MAFP believes the physician-led team approach delivers the best and most cost-effective care to Missourians and that APRNs are dedicated, skilled members of the health care team. • While APRNs have an important role on the health care team, they have not completed training that affords them the same experience and skill as those who have completed a medical education. A DNP completes approximately 5,350 hours compared to 20,000 hours for a physician. continued on page 26 MO-AFP.ORG 25

• Alternatives to an expanded scope of practice for APRNs are loan repayment/forgiveness/ scholarships for primary care physicians; less administrative burden, such as prior authorizations; increased reimbursement for primary care services; and expansion of primary care residency slots. • OPPOSE HB 1773 – Repealing most provisions of the current APRN collaborative practice agreements, as well as creating a new category of APRN licensure with increased scope of practice. • OPPOSE HB 1574 and SB 745 – By expanding the geographic proximity requirement and increasing the number of collaborative agreements a physician may enter into with an APRN from three to five, the team-based approach to medicine is drastically weakened because effective collaboration is much more difficult. EXPANSION OF ASSISTANT PHYSICIAN (see related article in this issue by Grant Hoekzema, MD on page 27) OPPOSE HB 2127 • MAFP supports efforts to increase physicians in rural, underserved areas through increased Missouri primary care residency slots and loan repayment/forgiveness programs. • The primary assumption that any care is better than no care, and anyone can provide primary care is false. This must be weighed against the principle that our underserved Missourians deserve safe, quality healthcare, preferably by a fully-trained family physician. • This bill expands the assistant physician practice to other specialties, not just primary care. • Medical school trains students to become residents, not physicians. • Assistant physicians currently licensed with collaborative practice agreements are not always located in rural, underserved areas as required by law and none have been trained in Missouri medical schools. • A small, but not insignificant, percentage of the assistant physicians would not be eligible for a physician license due to too many USMLE attempts and failures. • This legislation allows less training, supervision and stringency of requirements for licensure, all the while placing them in practices which may have less resources and specialty support but sicker than average patients. • Relaxes the boundary of time since medical school graduation and applying for a license from two to four years, without reassessment. In addition, they could leave, or be released from a residency, and still apply. PROTECT OUR PATIENTS • SUPPORT HB 1302, HB 1489, HB 1640, SB 749, SB 755, SB 784 – Amend texting while driving for all drivers, regardless of age; and prohibiting certain younger drivers from using any electronic wireless communication device (hands-free or not) while operating a vehicle. • OPPOSE HB 1389, HB 1426, HB 2158, HB 2481, SB 556 – Changes to the motorcycle helmet requirements.

aafp.org 26

MAFP CONTINUES TO SUPPORT EFFECTIVE OPIOID PRESCRIBING SUPPORT HB 1619, HB 1740, HB 2105, SB 737, SB 762, SB 825 • The MAFP supports a PDMP that monitors the prescribing and dispensing of controlled substances, requires dispensers to electronically submit specified information to the department within 24 hours of dispensation, and does not require a pharmacist or prescriber to obtain information about a patient from the database. • Missouri continues to be the only state without a PDMP. The PDMP with local jurisdiction continues to increase with 76% of the state population covered by the 54 participating cities and counties. (St. Louis Post Dispatch, November 8, 2017) • In 2016, the economic cost of the 921 opioid overdose deaths in Missouri was estimated at $12.1 billion. (HIDI Research, January, 2018) • The MAFP is concerned that expanding prescriptive authority of Schedule II medications to other mid-level providers increases the access and availability of addictive opioids. Evidence shows (AMA, 2017) that most physicians are reducing the number of opioid prescriptions written. Exceptions are nurse practitioners, physician assistants, and pain management physicians who have increased their number of opioid prescriptions.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

MEMBER PERSPECTIVE

Missouri's Assistant Physician Legislation: A Career Physician Educator's Perspective

n 2014, the Missouri legislature passed an omnibus bill that included a provision for the creation of a new category of physician licensure called the Assistant Physician (AP). The legislation was implemented in 2016 after the Missouri Board of Healing Arts finalized the rules and regulations governing the new license category. The first licenses were granted after January 1, 2017. Revision and expansion of the statute has been proposed in the Missouri House once again this year (HB 2127), which would make it easier to obtain an AP license and secure a collaborative

State legislatures have struggled with enacting creative legislative solutions to help solve these inequities in the distribution of their healthcare workforce. Missouri’s legislation creating the Assistant Physician, was passed in response to a concern regarding these shortages of providers in rural (and to a lesser degree, urban) underserved areas. The legislation was originally written to require an AP to be in a collaborative practice agreement, located in a designated medically underserved area or health professions shortage area. Those AP’s who were in collaborative practice agreements, at the time of this writing,

Grant Hoekzema, MD, FAAFP Mercy, St. Louis, MO

This legislation places patient safety and quality of care secondary to misguided health legislation and workforce policy."

practice agreement. As of the date of this publication, under the proposed revisions, any medical school graduate, who passes the first two steps of the USMLE or COMLEX within four years of graduation, would be able to practice in collaboration with a licensed Missouri physician. That practice, after only one month of direct supervision, could be located as far as 50 miles away, and could provide primary care, or other services, as deemed acceptable by the collaborating physician. Supervision would mirror that afforded to other fully licensed mid-levels. While originally intended to be time, scope and location limited, the expanded legislation will remove many of those restrictions. The revision also attempts to address concerns around CMS billing and malpractice, which were not clear in the original bill. To read the full current and proposed expanded legislation, please go to this summary available at https://legiscan.com/MO/ bill/HB2127/2018. Missouri has a shortage of primary care providers, as do many states with geographically large rural regions. Several barriers exist to recruiting qualified providers to the underserved areas of these states, including a lack of physicians willing to work in rural communities.

had practice addresses that were in large part located in the metro areas of St. Louis, Kansas City, Columbia or Springfield. This should give legislators and other state health officials concern that the legislation, initially, may not be meeting its intent to expand Missouri’s rural healthcare physician workforce. The expanded legislation would allow AP’s to practice in teaching hospitals or residency training programs, further diluting the original intent to help rural primary care needs. Currently, the definition of what qualifies as teaching sites is not specified and the scope and supervision that the AP would be afforded would certainly be in awkward contrast to the other graduate medical physician trainees. The perception exists that an excess of quality U.S. medical school graduates who do not match with a residency training program, could fill a gap in the healthcare workforce in underserved areas. There have been those who have made much out of the perceived imbalance between residency training positions and the surplus of medical school graduates who are vying for those positions in the National Residency Matching Program (NRMP). While it is true that there is an excess of 8,000 unmatched applicants each year in the NRMP over the last three years, the

continued on page 28

MO-AFP.ORG 27

MEMBER PERSPECTIVE

The AP category has effectively opened a career path for those wishing to practice medicine without residency training."

percentage of the matched applicants who are graduates of U.S. medical schools has not changed for decades, exceeding 95% each year. Data suggest that the majority of the unmatched medical school graduates are from international medical schools, many who are US citizens who went to train overseas. In addition, there is some evidence that these match applicants are not offered a position due to concerns about their academic and board exam performance. Thus, concerns that the U.S. is not able to adequately utilize its pool of highly trained medical school graduates, are not necessarily accurate. The current allocation of residency slots and the bias for medical students to gravitate towards nonprimary care specialties plays a large role in the maldistribution of our physician workforce needs. A further understanding of the motivation behind the AP legislation indicates that sponsors felt that the large numbers of medical school graduates, who did not match in the NRMP, were nevertheless qualified to provide primary care to those in underserved areas. Based on numerous media accounts, the sponsors of the legislation implied that the shortfall in the primary care workforce in Missouri could be partly addressed by allowing medical school graduates who did not secure residency training positions to practice in a collaborative arrangement similar to midlevel providers, such as nurse practitioners and physician assistants. The Missouri AP statute was enacted with the expressed purpose of placing these unmatched medical school graduates into underserved, preferably rural, communities, in collaboration with an existing practicing physician. The assumption behind this thinking is that any care is better than no care at all. In an age where patient safety and physician burnout are priorities, putting undertrained medical graduates, into resource poor settings, to practice with limited supervision, seems to fly in the face of these trends. The additional assumption that the care of those who lack resources or access is adequately served by anyone willing to do so, disrespects those Missourians who are disadvantaged. The paradigm shift regarding the potential of licensing of medical school graduates without residency training as a primary care workforce solution, has been a topic of debate and will be pushed to the fore by this new license category. Given that these licensees would be providing care with less supervision than required for residents in ACGME accredited residency

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

training programs, it would seem prudent to ensure that they were qualified to provide care in such a setting. The creation of the AP license category is unique in the United States, where most states require some post-graduate medical education in an accredited internship, residency or fellowship in order to obtain a physician’s license to practice. Currently Kansas, Utah, and Arkansas have similar licensure categories to allow medical school graduates, without any prior residency training, to practice; albeit with some significant differences. All three of those states either require the graduate to have been trained in a state medical school or to be a legal resident, and all have limitations on the length of time in which such a licensee can practice. Missouri’s time unlimited AP license category, as well as is its openness to any medical school graduate from around the world who meets the criteria, has opened the door to a new post-graduate practice pathway. Even if one assumes these positions are stepping stones to residency training, with a historically lower licensing exam pass performance, it would appear that the Missouri AP licensee pool would have potential hurdles in obtaining full licensure in the event they chose to attempt to complete residency training in the future. The practice of medicine without residency training was once common in the United States, but due to lack of standardization around training requirements, scope of practice and board certification, virtually all state medical boards adopted post-graduate training criteria for the unrestricted license to practice medicine. The AP category has effectively opened a career path for those wishing to practice medicine without residency training. Unfortunately, the upshot of this is that these practitioners have already begun to be lumped together with experienced, board certified physicians. It does not take much to put a physician into a “general practice” category when it comes to internet search tools. Already AP’s in practice are being classified as GP’s on sites that supply physician reviews to consumers and the public. Fully licensed physicians, trained to provide a broad scope of practice, in family medicine, would not want patients to be confused by these generic classifications, and assume they are going to receive equivalent care from an AP. It may be a slippery slope that results from this two-tiered system of entry into practice, with residency trained, board certified, family physicians being indistinguishable in the public eye from a medical school graduate, who is allowed to practice “primary care” potentially for an entire career, with limited supervision.

2018

8-9 June

conne ct

learn

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recharge

The Lodge at Old Kinderhook

Camdenton, Missouri

Keynote Speaker: Teri Ackerson, BSN, RN, SCRN, CNRN

It was Memorial Day, Teri Ackerson finished a six mile run in preparation for her next marathon, went home for a shower, then visited a Starbucks for a latte with her teenage son, Parker. Driving away, her grip on her coffee cup loosened as her left arm suddenly went numb. She felt the left side of her face droop down and she couldn’t speak. “Mom,” Parker said, “I think you’re having a stroke...”

Join us to hear about Teri's incredible journey...

We are dedicated to rural and underserved areas of our great state! Recognized as Missouri’s leading nonprofit health care focused job placement program, MHPPS helps health care professionals find a community that best fits their personal and professional needs. Find Out More: Contact Us Today! Opportuni�es throughout our Rura� � Ur�an Areas: Joni Adamson  �oan Repayment Op�ons Manager of Recruitment  Compe��e �a�ary � Comprehensi�e �ene�ts  Team �ased Mode�s of Care / Care Coordina�on jadamson@mo-pca.org / 573.636.4222 www.mhpps.org  �i��e or no Ca�� / Mo�ing A��owance / �igning �onus Proud Partners Of:

MHPPS is non-proﬁt and located within the MO Primary Care Associa�on MO-AFP.ORG 29

conne learn re lax ge conne ct ct learn lax rerechar charge Friday, June 8, 2018

Saturday, June 9, 2018

7:00 - 8:00 am

Registration and Breakfast Buffet with Exhibitors

7:00 - 8:00 am

Registration and Breakfast Buffet with Exhibitors

7:00 - 11:00 am

Exhibit Hall Open (Grand Ballroom A)

7:00 - 11:00 am

Exhibit Hall Open (Grand Ballroom A)

*All lectures will be held in Grand Ballroom B

8:00 - 9:00 am

Perspectives on True Palliative Care Timothy Ihrig, MD, MA

9:00 - 10:00 am

Ascertaining the Role of the Primary Care Clinician in the Recognition and Management of Patients with Multiple Sclerosis in the Modern Era Barry Singer, MD, PhD Sponsored by Peer View Institute for Medical Education

10:00 - 10:45 am

Refreshment Break with Exhibitors (Grand Ballroom A)

10:45 - 11:45 am

The Heart of Athletic Screening EKG's David Glover, MD, FAAFP

11:45 am - 12:00 pm

Break

12:00 - 1:00 pm

Luncheon Speaker: Help Wanted: No Experience Necessary (Hearth Room) Teri Ackerson, BSN, RN, SCRN, CNRN

1:00 - 1:15 pm

Break

1:15 - 2:15 pm

Health Through the Eyes of Culture Nick Comninellis, MD, MPH, DIMPH

2:15 - 3:15 pm

Perspectives in Primary Care: Evaluating and Managing Patients with Chronic Urticaria Anne Marie Ditto, MD Sponsored by Spire Learning and North Carolina Academy of Family Physicians

3:15 - 4:15 pm

Optimizing the Primary Care Workforce for Value-Based Care Nicholas Bartz, MBA

5:15 - 6:15 pm

Reception (Creek View Conference Center)

6:15 - 8:15 pm

Awards and Installation Dinner (Creek View Conference Center) • 2018 Family Physician of the Year Award • Soaring Eagle Award • Installation of President & Board Members • AAFP Degree of Fellow Convocation • Tar Wars Poster Contest Award

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

*All lectures will be held in Grand Ballroom B 8:00 - 9:00 am

Recruitment of Women and Minorities onto Clinical Trials at a NCI-Comprehensive Cancer Center and the Role of the Primary Care Physician Lannis Hall, MD, MPH

9:00 - 10:00 am

Breast Cancer Screening Recommendations Theresa Schwartz, MD, MS, FACS

10:00 - 10:45 am

Refreshment Break with Exhibitors (Grand Ballroom A) Prizes awarded. Must be present to win.

10:45 - 11:45 am

Reproductive Health Care: Conversations for Family Physicians and Their Patients Wael Mourad, MD, MHCM, FAAFP Sponsored by California Academy of Family Physicians

11:45 am - 12:00 pm

Break

12:00 - 1:30 pm

Annual Business Meeting and Legislative Luncheon (Creek View Conference Center)

1:30 - 1:45 pm

Break

1:45 - 2:45 pm

Do You See What Eye See: Primary Care Ophthalmology Gary LeRoy, MD, FAAFP

2:45 - 3:45 pm

No Bones About It: An Osteoporosis Update Beth Rosemergey, DO, FAAFP

3:45 - 4:45 pm

Resident and Student Poster Presentations Sponsored by Missouri Health Professional Placement Services

5:30 - 7:30 pm

Family Fun Fiesta Join us for an evening of fun-filled family activities! (Cabana Patio)

Sunday, June 10, 2018 9:15 - 11:00 am

Commission Meetings (Continental Breakfast in Grand Ballroom A) Advocacy - Grand Ballroom A Member Services - Red Oak Education - Cypress Room

11:00 am - 1:30 pm

Board Meeting with Working Lunch (Grand Ballroom A)

CUT AND MAIL TO MAFP

REGISTRATION FORM

Show Me Family Medicine Conference June 8-9, 2018 The Lodge at Old Kinderhook 678 Old Kinderhook Drive Camdenton, MO 65020 573.317.3500 or 888.346.4949 www.oldkinderhook.com

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Please complete this section if you received a letter notifying you of a Membership Anniversary.

□ Yes, I received my Membership Anniversary letter and will attend the Awards & Installation Dinner on Friday evening, June 8.

□ One complimentary guest will accompany me to the dinner. FOUR WAYS TO REGISTER: Online with credit card at www.mo-afp.org • Fax this form to (573) 635-0148 • Call us at (573) 635-0830 • Mail this form with payment to: MAFP, 722 West High Street, Jefferson City, MO 65101-1526 REGISTRATION CANCELLATIONS must be in writing and received by MAFP no later than May 8, 2018. MAFP policy requires a $50 administrative fee be deducted from each refund processed. Questions? Call (573) 635-0830 or email: office@mo-afp.org.

RSVP & GUEST OPTIONS

Syllabus Materials

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download online version (available closer to conference) Free for Life Members

Will you be conferred at the Fellow Convocation? If yes please deduct $50 from your total. You are allowed one guest (complimentary).

□I am being conferred □Yes, I will bring a guest Early-Bird Discount (until 5/8/2018) *Does not apply to 1-day registration FHFM Donation (Tax Deductible) Tax ID 43-1480324

Optional $ Registration Total $

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$25

Saturday Lunch: Annual Business Meeting & Legislative Luncheon

□Yes

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$25

Saturday Dinner: Family Fun Fiesta

□Yes

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$ $

Family Fun Fiesta (Child age 5-12)

xxxx

$10

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Free

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CME sessions, meals, breaks, and electronic syllabus are included in the registration fee. All functions in the exhibit hall are for registrants only. 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.

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3-Digit Security Code MO-AFP.ORG 31

RESIDENT GRAND ROUNDS

Electronic Cigarettes: Smoking Cessation Tool or Public Health Nightmare?

E Andrew Peterson, MD, MPH University of MissouriColumbia Department of Family and Community Medicine

lectronic nicotine delivery systems, or ENDS, are better known by their more common name, e-cigarettes.1 They are battery operated products that are designed to heat a coil on inhalation. The coil vaporizes a liquid solution which is then inhaled. The solutions (“e-juices”) are typically made of propylene glycol and/or vegetable glycerin in which nicotine and aromas are dissolved. Their popularity is rising, and recent advances in research should prompt physicians to evaluate e-cigarette safety, public health impact, and role as a possible cigarette smoking cessation method. E-cigarettes hit the market in the United States in 2007. Independent manufacturers not associated with the “Big Tobacco” companies brought them to market, and they were initially available in convenience stores as disposable products. At that time, one e-cigarette was similar in nicotine content to a traditional cigarette, and would last roughly as long as a pack of cigarettes. In 2008, privately owned “vape shops” began popping up in cities around the United States. These Vape Shops were independently owned and supplied e-cigarette users with re-usable devices that were modifiable, as well as e-juices with multiple flavors and multiple nicotine strength. By 2014, there were an estimated 35,000 Vape Shops in the United States.2 As e-cigarette popularity rose, consumer advocates began to question their safety and health effects. E-cigarettes are nicotine products, but not tobacco products, and are not subject to regulatory processes that apply to combustible nicotine products (cigarettes). E-cigarette products were not mandated to provide ingredient lists for instance. While combustible tobacco products have been bound by advertising and television marketing restrictions since the 1970s, e-cigarette manufacturers were able to market their products in magazines and on television. This could have played a role in their continued rise in popularity: 3.3% of adults reported everuse of e-cigarettes in 2010 compared to 12.6% of adults in 2015.3 Long term health consequences of e-cigarette use remain unknown. Studies have found multiple chemicals in e-juices that are known respiratory irritants.4 It is difficult to make

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

predictions on long term health effects given that different e-juices have different flavorings and differing concentrations of chemicals that are harmful. Other factors are at play that affect the inhalation of these irritants as well include the type of coil and battery present in an e-cigarette, and how intensely an individual inhales. As their popularity climbed, “Big Tobacco” companies took notice. In 2012, Lorillard Tobacco Company purchased Blu e-cigarettes for 135 million dollars. Nu Mark then later purchased GreenSmoke, another popular e-cigarette product. For the “Big Tobacco” companies, these acquisitions allowed them to establish a large stake in a proven market of the future, while eliminating two of what would be the biggest competitors if they were to brand their own electronic cigarette. The U.S. Food and Drug Administration (FDA) has regulated cigarettes, roll-your-own, and smokeless tobacco since 2009 with the Family Smoking Prevention and Tobacco Control Act. In May of 2016 the FDA extended its regulatory authority to include e-cigarettes, including associated components. This extension also included hookah, cigars, pipe tobacco, nicotine gels, and nicotine dissolvables.5 This regulation allows the FDA to standardize the manufacturing, distribution, and marketing of these products. New rules prohibited sales to those less than 18 years old, added nicotine warnings to packaging, demanded that manufacturers meet quality standards, and include ingredient lists, among other requirements. The FDA initially gave manufacturers and retailers two years to become compliant, but recently pushed back the deadline to 2022 to allow more time for public comment and industry guidance. The agency cited an aim to “develop an appropriate balance between regulation and encouraging development of innovative tobacco products that may be less dangerous than cigarettes,” and stated that “nicotine is delivered through a continuum of risk and is most harmful when delivered through smoke particles in combustible cigarettes.”6 Given the prevalence of e-cigarette us in the United States and the public health impact that e-cigarettes pose, it is important for clinicians to be knowledgeable on the health effects, trends,

and roles that electronic cigarettes play in the lives of our patients. The National Academy of Sciences, Engineering, and Medicine (NASEM) expert panel recently released an extensive report reviewing and consolidating available information encompassing multiple aspects of e-cigarette use.4 Health Effects: There are no long term data on the health effects of e-cigarettes given their relatively short duration of availability. A 2014 review article summarized data that compared inhaled components between tobacco cigarette smoke and electronic cigarette vapor. After summarizing findings from four studies that evaluated and compared air quality, they reported that e-cigarette vapors contain “far less carcinogenic particles” than cigarette smoke, and concluded that e-cigarette vapors impart a lower potential disease burden than conventional cigarettes.7 Although health effects in the user seems to be an improvement from combustible tobacco

in the short term, long term exposures are still unknown. The long term health consequences of cigarettes are well established with their known 100 group 1 (carcinogenic to humans) chemicals, as well as 800 others with cancer causing potential between both group 2A (probably carcinogenic to humans) and 2B (possibly carcinogenic to humans).7 It is important to note some other possible health effects beyond inhalation of the aerosol. E-liquids can be dangerous if there is exposure to the skin or oral ingestion. There have been 16 case reports of poisonings due to exposure to e-juice via oral or dermal routes.4 There have been reports of the e-cigarettes malfunctioning and causing explosions and burns. E-cigarette or e-juice exposure calls across the U.S. to Poison Control Centers increased from one per month in September 2010 to 215 per month in February 2015.8 Also, e-cigarette exposure calls were more likely to report an adverse health effect such as nausea, vomiting, or eye irritation, than cigarette exposure calls.

continued on page 34

MO-AFP.ORG 33

Use and Trends: United States surveys from 2010 to 2015 indicated a sharp increase in ever use of e-cigarettes from 3.3% of adults to 12.6% of adults, with an increase in recent (within 30 days) use from 1.3% to 3.7% of adults.3 Users tend to be younger, more educated, and have higher incomes. The same survey data revealed the highest prevalence of e-cigarette use in current cigarette smokers (16%) and former cigarette smokers who had quit in the past year (22%). Given the historically less restrictive regulatory environment, use among adolescents and potential association with increased combustible nicotine products is concerning.9,10 One 2018 prospective cohort study with a nationally representative sample of 10,384 adolescents followed for 12 months showed that users of e-cigarettes were nearly twice as likely to report cigarette use in the past 30 days.9 Another 2015 cohort study followed 2,530 high school freshmen for 12 months. Compared to non-users, students reporting any baseline use of e-cigarettes were more likely to report cigarette use within the past six months.10 The NASEM report concluded that there is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.4 Role as Smoking Cessation Tool: Given the nicotine component of e-cigarettes, it is logical to evaluate their possible role as a method if nicotine replacement therapy to help cigarette users quit smoking or decrease exposure to combustible tobacco products. A July 2017 United States cross sectional study (n=161,054) compared data from the 2014-15 survey to prior years (including 2001-02, 2003, 2006-07, 2010-11).3 E-cigarette use was higher in 2015 than any previously reported period. E-cigarette users were more likely than non-users to attempt to quit combustible cigarettes (65.1% v 40.1%, 25% change, 95% CI 23.2-26.9%, P<.001), and they were more likely to succeed in quitting combustible cigarettes (8.2% v 4.8%, 3.5% change, 95%CI 2.5-4.5% P<.001). Quit rates for cigarette users were stable over previous surveys, but the rate of successful quitting increased significantly in the 2014-15 survey (4.5% successful quit rate versus 5.6% quit rate, 1.1% change, 95% CI 0.6-1.5%, P<.001). These changes do correlate to the increase in e-cigarette use, but do not prove a causative relationship. A 1.1% difference in quit rate would equate to roughly 350,000 fewer US adult smokers. There are few randomized controlled trials 34

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

to evaluate e-cigarettes as a method of nicotine replacement therapy for smoking cessation, and those published are small with limited comparisons to other quit methods or medications. The largest randomized controlled trial (N=657) to this point was a superiority trial that compared e-cigarettes (both with and without nicotine) to nicotine patches for smoking cessation with a primary outcome of continuous abstinence from cigarettes at 6 months.11 Unfortunately, overall achievement of abstinence was substantially lower than anticipated for the power calculation, so statistical significance was not met to conclude superiority of e-cigarettes to patches. However, some numbers in this study are intriguing as e-cigarettes reached similar achievement of abstinence as patches. After six months of use, 7.3% of the nicotine e-cigarette group and 5.8% of the patch group were abstinent from cigarettes (RR 1.77, 95% CI 0.54-5.77). It was also interesting to note that the e-cigarettes seemed to be better tolerated than patches, with adherence to treatments being significantly higher (P<0.0001 at each visit) in the nicotine e-cigarette group at one (78% still using e-cigs vs 46% still using patches), three (51% vs 18%), and six (29% vs 8%) month follow-up compared to the patches group at every follow up visit. Also, 57% of e-cigarette using subjects had decreased daily cigarettes by at least half at six months, a significantly greater proportion than those using patches (41%, p=0.0002).11 After reviewing 17 systematic reviews and three randomized controlled trials, the NASEM report concluded that there is limited evidence at this time that e-cigarettes may be effective aids to smoking cessation. They also reported moderate evidence from observational studies that more frequent use of e-cigarettes is associated with an increased likelihood of cessation. They also concluded that there is insufficient evidence at this time from RCTs about the effectiveness of e-cigarettes as cessation aids.4 Take Home Points: Physicians and patients have much to learn about electronic cigarettes, most notably their potential role in tobacco cessation and their long term health effects. Available research indicates that they are potentially less harmful than traditional cigarettes, but increasing rates of use and association with cigarette use in adolescents is concerning. Here are some important points for clinicians to remember when caring for both adult and pediatric patients:

• Include e-cigarette use when discussing tobacco use with your patients, particularly adolescents. E-cigarette use in this age group appears to increaseincreases the likelihood they will use cigarettes. • In patients using e-cigarettes, encourage complete cessation of combustible tobacco products. • Remind patients of the dangers of e-juices including ingestion and skin exposure. E-juice containers should be kept out of reach of children. • Encourage complete cessation of e-cigarette use, as long term health effects are still unknown. 1 - U.S Food & Drug Administration. (2017). Vapes, E-Cigs, Hookah Pens, and other Electronic Nicotine Delivery Systems (ENDS). Last Updated 09/18/2017. Silver Spring, MD. https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ ucm456610.htm#regulation. Accessed October 16, 2017 2 - Esterl, Mike "Big Tobacco's E-Cigarette Push Gets a Reality Check". (26 August 2014). The Wall Street Journal 3 - Zhu Shu-Hong, Zhuang Yue-Lin, Wong Shiushing, Cummins Sharon E, Tedeschi Gary J. (2017). E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys BMJ 2017; 358 :j3262 4 - The National Academies of Sciences, Engineering, and Medicine. (2018). Public Health Consequences of E-Cigarettes. Health and Medicine Division. January 23 2018 5 - U.S Food & Drug Administration. (2017). FDA’s New Regulations for E-Cigarettes, Cigars, and All Other Tobacco Products. Last Updated 12/27/2017. Silver Spring, MD 6 - Ellis, James. (2016) Vaping: Big Tobacco’s Big Gamble On The Future. Apr 24 2016. Newsweek. Newsweek LLC. http://www. newsweek.com/vaping-big-tobacco-big-gamble-future-451074. Accessed October 29, 2017 7 - Oh, A. Y. and Kacker, A. (2014). Do electronic cigarettes impart a lower potential disease burden than conventional tobacco cigarettes?: Review on e-cigarette vapor versus tobacco smoke. The Laryngoscope, 124: 2702–2706. doi:10.1002/lary.24750 8 - Centers for Disease Control and Prevention. (2014). Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes – United States, September 2010-February 2014. April 4, 2014. 63 (13); 292-293. https://www.cdc.gov/mmwr/preview/ mmwrhtml/mm6313a4.htm?wptouch_preview_theme=enabled 9 - Watkins SL, Glantz SA, Chaffee BW. (2018). Association of Noncigarette Tobacco Product Use With Future Cigarette Smoking Among Youth in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015. JAMA Pediatr.2018; 172(2): 181-187. Published Online January 2, 2018 10 - Leventhal, A. M., Strong, D. R., Kirkpatrick, M. G., Unger, J. B., Sussman, S., Riggs, N. R., Audrain-McGovern, J. (2015) Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA, 314(7), 700–707. http:// doi.org/10.1001/jama.2015.8950 11 - Bullen, Christopher et al. (2013). Electronic cigarettes for smoking cessation: a randomised controlled trial. The Lancet, Volume 382, Issue 9905 , 1629 - 1637

care. H M C

Citizens Memorial Hospital is recruiting Family Medicine physicians for a variety of openings in beautiful Southwest and West Central Missouri. Opportunities include: • Full Scope Family Medicine • Family Medicine with Surgical OB • Family Medicine with Geriatrics • Outpatient Family Medicine and Urgent Care Donna Shelby, Director of Physician Recruiting donna.shelby@citizensmemorial.com (p) 417-328-6273 • (c) 417-399-4333 (f) 417-328-1130 • citizensmemorial.com

citizensmemorial.com MO-AFP.ORG 35

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HDAs HelpDesk Answers

Do Prescription Monitoring Databases Decrease Prescription Opiate Abuse? EVIDENCE-BASED ANSWER

John A. Campbell, MD, CMD, FAAFP Mercy Family Medicine St. Louis, MO

Ann Lottes, MD Resident

Alex Mazzaferro, MD Resident

Circumstantial evidence suggests they may. Statewide prescription drug monitoring programs (PDMPs) are associated with a decrease in opioid-related overdose deaths by 1.12 per 100,000 population. PDMPs are also associated with a 30% decrease in office visits in which Schedule II opioids are prescribed, and when combined with other legislation, are associated with substantial decreases in total volume of opioids prescribed in the United States (SOR: B, retrospective cohort studies).

EVIDENCE SUMMARY

2016 retrospective interrupted time-series analysis evaluated the association between implementation of PDMPs and the rate of opioid-related overdose deaths.1 This analysis compared opioid-related overdose death rates in the year legislation called for establishment of databases with rates in the year after implementation of the databases for the 34 states that implemented PDMPs between 1999 and 2013. While overall opioid-related overdose deaths rose from 1.36 per 100,000 population in 1999 to 6.21 per 100,000 population in 2013, PDMP implementation was associated with a decrease in opioid-related deaths of 1.12 per 100,000 population in the year after implementation (95% CI, 0.55–1.7).1 A 2016 retrospective cohort study assessed the effect of implementation of PDMPs on opioid prescribing in 24 states that implemented a program between 2001 and 2010.2 A survey of physicians regarding visits occurring during a randomly selected

Alexander Meyer, DO Resident

Interested in more HelpDesk Answers? Get the answers to your clinical questions with a complementary 3 month electronic subscription to

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one-week period yielded 26,275 ambulatory care visits for pain. The study population included adults who reported pain as one reason for a physician’s office visit. Outcome measures included prescriptions for opioid pain medications written at the visits before and after implementation of the PDMP. Implementation of a PDMP was associated with a 30% reduction in ambulatory visits with prescriptions written for Schedule II opioids—from 5.5% of visits to 3.7% of visits; P<.01)—which persisted for at least three years.2 A 2015 retrospective interrupted time-series analysis characterized the effect of a PDMP and “pill mill” law implementation in Florida on volume of opioids prescribed compared with Georgia from July 2010 to June 2011 (preimplementation) and from October 2011 to September 2012 (postimplementation).3 “Pill mill” laws required these clinics to register with the state; create inspection, prescribing, and dispensing requirements; and to be owned by a physician. The study analyzed 480 million prescriptions for 2.6 million patients, written by 431,890 prescribers in both states, 7.7% of which were for opioids. From preimplementation to postimplementation, total volume of opioids prescribed decreased 4% in Florida (from 327 to 314 kg) and 2.3% in Georgia (from 118 to 116 kg). This equates to a 2.5 kg per month greater opioid-prescribing reduction in Florida compared with Georgia (P<.05). However, no difference was noted between the two states in change in number of opioid prescriptions. Decreases were most significant among the highest volume prescribers and patients.

1. Patrick SW, Fry EC, Jones TF, Buntin MB. Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates. Health Aff (Millwood). 2016; 35(7):1324–1332. [STEP 3] 2. Bao Y, Pan Y, Taylor A, Radakrishnan S, Luo F, Pincus HA, et al. Prescription drug monitoring programs are associated with sustained reductions in opioid prescribing by physicians. Health Aff. 2016; 35(6):1045–1051. [STEP 3] 3. Rutkow L, Chang HY, Daubresse M, Webster DW, Stuart EA, Alexander GC. Effect of Florida’s prescription drug monitoring program and pill mill laws on opioid prescribing and use. JAMA Intern Med. 2015; 175(10):1642–1649. [STEP 3] MO-AFP.ORG 37

issouri officials are addressing the opioid misuse epidemic by trying to reduce the number of opioid prescriptions physicians in the state provide to Medicaid patients, but the Missouri AFP and the AAFP recently collaborated to warn that the state's overly broad actions could threaten patient care. Earlier this month, Gov. Eric Greitens announced (governor.mo.gov) that the state has started contacting physicians and other health care professionals who, officials say, "prescribe too many opioids." In 2017, the announcement stated, more than 8,000 Medicaid prescribers in the state "whose prescribing habits do not adhere to one or more Quality Indicators pertinent to the use of an opioid for management of pain" were identified. On March 9, MO HealthNet, the state's Medicaid program, sent letters to all of the state's Medicaid prescribers (dss.mo.gov) informing them of changes to MO HealthNet's Opioid Prescription Intervention Program, including calling for opioid prescribers to adhere to the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, (www. cdc.gov) which focuses on pain lasting longer than three months. Prescribers "whose prescribing activity results in flagging one or more Quality Indicators" related to opioid prescribing would receive additional communication regarding their specific activity, the letter noted. Those who fail to adequately explain their prescribing activity within 20 days of receiving a second letter from the state would be referred to their state licensing board and the Missouri Department of Social Services.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

In response, the AAFP collaborated with the Missouri AFP in a March 13 letter (see letter on next page) addressed to Greitens and the respective directors of the state departments of Health and Senior Services, Social Services, and Mental Health that also copied the Missouri Senate and House of Representatives. The letter, signed by Missouri AFP President Mark Schabbing, M.D., of Perryville, pointed out that the guideline was never meant to be a law, and that the state's drastic action could harm patients who depend on prescription medication. Moreover, the letter notes that many of the recommendations in the CDC guideline are based on insufficient evidence and that "the guideline did not meet the National Academy of Medicine's standards for clinical practice guidelines." Although family physicians do consult the guideline, treatment should be based on shared decision-making between physician and patient using all available evidence. "If the guideline were to be implemented as a rule, regulation or law, physician discretion and decision-making would be undermined and patient care would suffer," the letter stated. The letter highlighted other consequences that could occur as a result of the state's action, especially considering the significant barriers to nonpharmacologic treatment options for pain in public and private health insurance plans.

"We fear that this would cause significant disruption to care for patients who are currently receiving long-term chronic pain treatment," the letter stated. "Patients who

have an established treatment plan with their physician should not have this disrupted due to a change in law." State officials used the Medicaid database to track prescription patterns, reporting that 1.2 million prescriptions were given to Medicaid patients. But the Missouri AFP noted that national opioid prescribing is decreasing for most physicians even as it is increasing among advanced practice registered nurses and physician assistants. Helping patients move away from opioid dependence requires long-term treatment, and

the letter cautioned that Missouri's health care system does not have the capacity to treat a high volume of patients who are suddenly cut off from opioid treatment. "While decreasing access to opioids is critical to tackling the opioid epidemic, it is imperative that treatment regimens are supported, helping to wean patients from misuse," the letter stated. "The opioid epidemic is devastating to our state and the patients we treat every day. We are on the same team."

Missouri Answers Back Below is Missouri's response, in collaboration with the AAFP, in a March 13 letter addressed to Governor Greitens and the respective directors of the state departments of Health and Senior Services, Social Services, and Mental Health that also copied the Missouri Senate and House of Representatives: Dear Governor Greitens, et. al.: On behalf of the Missouri Academy of Family Physicians (MO-AFP), which represents more than 2,400 family physicians and medical students across Missouri, I write in response to the recent letters sent to prescribers from MO HealthNet flagging opioid prescriptions that were outside of the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain. The MOAFP has strong concerns with any efforts by the Department of Social Services (DSS), Department of Mental Health (DMH), or Department of Health and Senior Services (DHSS) to enforce or codify the CDC Guideline as written. Missouri’s family physicians are committed to responsible prescribing of opioid medications and we value and consult the CDC’s Guideline for Prescribing Opioids for Chronic Pain. However, these and other medical voluntary guidelines are meant to be used by prescribers as they work in consultation with their patients to address chronic pain. Treatment decisions should be kept between the physician and patient and in the context or shared decision making while following the available evidence. If the Guideline were to be implemented as a rule, regulation, or law, physician discretion and decision making would be undermined and patient care would suffer. Ultimately, the CDC Guideline was meant to be a recommendation, never a law. The American Academy of Family Physicians (AAFP) has accepted the CDC Guideline as useful guidance, but decline to fully endorse it, as many of the Strong category recommendations were based on limited or insufficient evidence, and the Guideline did not meet the National Academy of Medicine’s standards for clinical practice guidelines. These weaknesses are identified in the Guideline itself: “Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context. The recommendations in the Guideline are voluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations. Clinicians should consider the circumstances and unique needs of each patient when providing care.” https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm As the most visited specialty, particularly in rural and underserved areas, family physicians find themselves at the crux of the issue, balancing care for patients with chronic pain and the challenges of managing the appropriate use of opioids, ever mindful of their potential for misuse or abuse. In the face of opioid misuse, family physicians have a unique opportunity to be part of the solution. MO-AFP stands ready to work with stakeholders and policymakers to identify strategies to decrease the opioid supply and provide treatment to patients who are suffering from opioid and other substance use

continued on page 40 MO-AFP.ORG 39

disorders (OUD/SUD). Beyond the issue of the rigidity of the Guideline, we fear that this would cause significant disruption to care for patients who are currently receiving long-term chronic pain treatment. While there is some evidence to support non-pharmacologic treatments for chronic pain, regrettably, barriers to non-pharmacologic therapies for chronic pain exist in public and private health insurance plans. Additionally, patients who have an established treatment plan with their physician should not have this disrupted due to a change in law. While decreasing access to opioids is critical to tackling the opioid epidemic, it is imperative that treatment regimens are supported, helping to wean patients from misuse. Opioid dependence is an illness that needs long-term treatment. We have significant concerns that Missouri’s current treatment infrastructure does not have the capacity to absorb a large number of patients newly cut off from opioid treatment. The Missouri Workforce Coalition states Missouri has 15,791 physicians in 2016 and 5,294 are primary care physicians. Based on the 8,000 letters being sent, approximately 50% of all physicians are being asked to respond to a letter that has been sent to the “bad actors who put greed, ease, or profit ahead of their mission to help people” as stated in Governor Greitens’ press release. Yet, it doesn’t address the national research (American Medical Association, 2017) showing mid-level providers (advanced practice registered nurses and physician assistants) whose prescribing of opioids is increasing, where most physicians (except pain management) prescribing is decreasing. Finally, this well-intended mandate would add to the administrative complexities that already plague family medicine. Administrative burden affects physicians and patients alike, and results in reduced face-to-face time with patients. Our current payment models, disparity in reimbursement for Medicaid patients, coupled with a crippling regulatory structure, threaten patient access to evidence-based pain care and OUD and SUD treatment from primary care physicians. Adding paperwork will take doctors away from patient care. The opioid epidemic is devastating to our State and the patients we treat every day. We are on the same team. The MO-AFP reiterates our commitment to helping lawmakers promote policies that will prevent the misuse of prescription opioids, and we strongly support increased access to new SUD treatments, eliminating barriers to treatment, and the creation of a prescription drug monitoring program. We look forward to working with you to find a solution to save all Missourians surviving the disease of addiction. We appreciate the opportunity to provide these comments and make ourselves available for any questions you might have.

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MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

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MO-AFP.ORG 41

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MEMBERS IN THE NEWS Welcome, Beth Rosemergey, DO, FAAFP

Koopman Takes on Advocacy

The MO-AFP Board of Directors would like to welcome Dr. Beth Rosemergey as the Alternate Director for the Kansas City District. Rosemergey, a graduate of the Kansas City University of Medicine and Biosciences, completed her family medicine residency at UMKC. She served as the program’s chief resident before joining the faculty as an Rosemergey assistant professor of medicine in 1992. Since 2014, Rosemergey has served as vice president of outpatient care, medical director of the Bess Truman Family Medical Center, and medical director of the Lakewood Pavilion. She has also served on the UMKC Honor Council and as the UMKC Faculty Council representative for TMC Lakewood.

Welcome Peter Koopman, MD, FAAFP, to the MO-AFP Advocacy Commission as CoChair. Dr. Peter Koopman is a graduate of the University of Pittsburgh Medical School class of 1992. He pursued a year of Internal Medicine training at the University of Pittsburgh Medical Center before hearing the call to Family Medicine. A three Koopman year residency at St. Margaret's Memorial Hospital in Pittsburgh was then completed in 1996. For ten years he practiced full time rural and then urban Family Medicine in Florida and then South Carolina before hearing a new call to academics. Since 2007 he has been on faculty at the University of Missouri Family and Community Medicine Program.

Richter Recognized as Future Leader Jessica Richter, DO, PGY3, UMKC Family Medicine Residency Program, received a scholarship from the Missouri Society of the American College of Osteopathic Family Physician’s (MSACOFP) in the amount of $1,000. This scholarship was established to help identify and develop future leaders for the MSACOFP and family medicine in Missouri. The scholarship was presented at the Annual Membership meeting and Awards at the Society’s annual Winter Family Medicine Update on Saturday, January 27, 2018. Residents selected for the scholarship were invited to attend the MSACOFP Winter Scientific Conference, and were asked to sit on the Educational Planning committee for the Society. Dr. Richter recently finished a one-year term as Resident Representative on the MSACOFP Board of Governors, and while attending the annual membership meeting, was selected to continue to sit on the board for an additional three-year term.

NEWS TO SHARE?

MSACOFP President, C. Mark Rose, DO, presents the award to Dr. Richter.

The Missouri Family Physician magazine welcomes your input. Please submit newsworthy items for review to: office@mo-afp.org MO-AFP.ORG 43

2018

Match®

Results for Family Medicine The American Academy of Family Physicians’ (AAFP’s) brief analysis of the family medicine results of the annual National Resident Matching Program (NRMP) Main Residency Match® (NRMP Match) provides a snapshot of a major input into the primary care workforce pipeline.

2018 NRMP Match Highlights

• 3,535 medical students and graduates

matched to family medicine residency programs in 2018, the most in family medicine’s history as a specialty, and 298 more than 2017.

• Of those matches, 1,648 positions were filled with U.S. Seniors, an increase of 118 since 2017, yet still fewer than the historical peak (2,340 in 1997), and only 9.3% of U.S. Seniors matching. • Family medicine offered 3,654 positions, 276 more than 2017, yet only 12% of positions offered overall, far off the goal of at least 25% by 2030.

John Heafner, MD and wife, Nicole, pose for a photo during The Match. John will be completing his residency at St. Louis University.

• This is the ninth straight year that the family medicine match results climbed year-over-year, and the second largest year-over-year increase during that stretch.

UMKC celebrated The Match by having lunch and a revealing of the class of 2021.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

Marina Tawfik shows off her match at St. Louis University.

Congratulations to all!

Achieve healthier outcomes—for everyone. In its first major development for The EveryONE Project, the AAFP compiled an in-depth toolkit to help physicians recognize and respond to social factors that impact the health of patients. The EveryONE Project toolkit is validated, intuitive, action oriented, and free. Utilize it to: • Raise awareness about the effects of social determinants of health. • Discover specific health risks in patients of all backgrounds. • Understand and manage potential biases that may exist. • Connect patients with essential resources in their area. Reveal and address the unseen health hurdles your patients face every day. Start using The EveryONE Project toolkit now.

aafp.org/EveryONE/tools

The EveryONE Project Advancing health equity in every community MO-AFP.ORG 45

MAFP Leadership Meets with MDHSS Director

Kathy Pabst, MBA, CAE Executive Director

our MAFP leaders, both past and present, met earlier this year with Randall Williams, MD, FACOG, Director, Missouri Department of Health and Senior Services (MDHSS), and had a lively dialogue about issues important to both the Academy and to the MDHSS. Dr. Williams believes “a fundamental tenet of effective leadership is to be readily available and accessible.” You may have had an opportunity to meet him as he has visited all of Missouri’s 115 counties to listen and learn from all of Missouri’s citizens. We were prepared with an agenda of items from workforce issues, scope of practice, the opioid epidemic, and patient safety, among others; however, the conversation flowed from topic to topic with ease and the agenda was never referenced. A casual conversation ensued with facts and figures, that gave way to a vision that focused on providing the better care for our patients, resulting in better health, at an affordable cost...the triple aim. As the Annals of Family Medicine (November/December, 2014) article proposes a fourth prong to change it to the quadruple aim of including health care clinician satisfaction. This topic was not overlooked as we talked about physician burnout and the administrative burden from the government, third party payers, and employers, that is overwhelming the daily practices of you, our members. Mark Schabbing, MD, President; Sarah Cole, DO, President Elect; Jim Stevermer, MD, Secretary/Treasurer; Keith Ratcliff, MD, Advocacy Commission Chair, Todd Shaffer, MD, Past President, Kathy Pabst, Executive Director, and your new lobbyists, Randy Scherr and Brian Bernskoetter, were resources to Dr. Williams’ exchange of ideas and inquisitive conversation. Workforce issues drove much of the discussion and the subsidiary issues of recruitment of family physicians to rural areas, independent practice of nurse practitioners, and loan repayment, forgiveness, and scholarships. As you know, these are priority issues for the MAFP, and we found that they are important to Dr. Williams too. Even though we did not agree on how to resolve these issues, we did identify common ground to build upon to advance our mission.

MISSOURI FAMILY PHYSICIAN APRIL-JUNE 2018

Dr. Shaffer’s responsiveness during the discussion on Missouri’s workforce needs further defined the workforce shortage that we are all aware of. “He [Dr. Williams] really has a pulse of what is needed for our state to improve medical outcomes and he told us so many times that it is a strong family medicine base that improves access to care, psychiatry care, and prevention all across our state. He outlined plans for increased primary care reimbursement and support for teaching institutions.” Dr. Shaffer emphasized the economic engine that each family doctor provides in smaller communities as also important for the economic and health support that our Missouri rural communities so desperately need. Dr. Williams stated that family physicians are the “lynch pin” for behavioral health to aid in the fight against the opioid epidemic and abuse. We couldn’t agree more...many rural communities do not have psychologists, psychiatrists, or counselors...instead patients see their family physician for this care. “Primary care clinics are developing treatment models for opioid use disorder, but few are integrating comprehensive behavioral health strategies to improve outcomes.” Annals of Family Medicine (January/ February, 2018) “It is encouraging to have a physician at the helm of MDHSS again. It’s clear he is dedicated to hearing patient and health provider perspectives from every county in our state and is looking for cost-effective, evidencebased strategies to reduce health disparities in Missouri” said Sarah Cole, DO, MAFP President Elect. When looking at the economies of Missouri’s rural communities, Dr. Williams referenced an article in the Chronical for Higher Education about Kennett, a small, rural town in southeast Missouri, and the county seat for Dunklin County. “Educational disparities, economic malaise and lack of opportunity are making people like those in the Bootheel sick, and maybe even killing them,” according to the article. Community revitalization is based on jobs, schools, and healthcare. Again, a three-pronged approach for improvement and family physicians are there treating chronic diseases and encouraging positive healthy lifestyles. The integration of

the triple aim, better care, better health, and lower costs, brings together public health and primary care to improve patient outcomes. The article continues to co-relate better health care with education, and education is a challenge in our rural communities. But what if, as Dr. Williams suggested, we recruited students from our rural communities, provided scholarships for them to go to medical school, with a commitment to return to their communities to set up practice. These students need an opportunity and this could be it – solving all three components of a community’s revitalization: jobs, education, and healthcare. Opportunities and ideas continued, doors have been opened, and the Missouri Academy of Family Physicians looks forward to working with Dr. Williams to provide our position on important issues and be a resource to him and his department. Dr. Ratcliff summarized our meeting clearly, stating, “We found our meeting with Dr. Williams to be productive and gracious." It is refreshing that after years of different leadership perspectives, our Governor has chosen a physician to lead our MDHSS. Given the right tools and authority, Dr. Williams can provide a more patient-centered path, and can understand the unique perspective of our family physicians in delivering the needed care for our state." References: Annals of Family Medicine, From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider, Thomas Bodenheimer, MD, and Christine Sinsky, MD, November/December, 2014. Annals of Family Medicine, Interdisciplinary Management of Opioid Use Disorder in Primary Care, Rebecca E. Cantone, MD, Joan Fleishman, PsyD, Brian Garvey, MD, MPH, and Nicholas Gideonse, MD, January/February, 2018. Chronicals of Higher Education, A Dying Town, Sarah Brown and Karin Fischer, December 29, 2017.

He [Dr. Williams] really has a pulse of what is needed for our state to improve medical outcomes and he told us so many times that it is a strong family medicine base that improves access to care, psychiatry care, and prevention all across our state. He outlined plans for increased primary care reimbursement and support for teaching institutions.” - Todd Shaffer, MD MAFP Past President

Smart Start Beef as a First Food for Infants Laying the foundation for a healthy lifestyle begins early in a child’s life with the introduction of solid foods. Starting around six months of age, complementary foods are essential to reduce vitamin and mineral deﬁciencies during this period of rapid growth and development.1 In fact, the World Health Organization guidelines for complementary feeding recommend daily intake of animal source foods to ensure that nutrient needs are met.2 It is reported that less than 10 percent of infants consume meat in the ﬁrst nine months of age.3 However, the American Academy of Pediatrics advises that meat, including beef, be introduced as an early solid food in an infant’s diet, since proper nutrition during this critical time sets the stage for continued development and lifelong health.1

STARTING STRONG FOR OPTIMAL GROWTH Beef contains essential nutrients to fuel a child’s early growth and development. With nutrients like zinc, iron and protein, along with vitamins B6 and B12, choline and selenium, beef as a complementary food is associated with normal physical growth in infants.4, 5 Recent research has shown that high protein intake from meat as a complementary food favorably increases growth but not adiposity in breastfed infants.5

INTRODUCING VITAL NUTRIENTS FOR A BUDDING BRAIN Infants and toddlers need protein, iron and zinc to support brain health and optimal cognitive development. Iron deﬁciency can have long-term eﬀects on learning, behavior and neurodevelopment.6 Studies show that the iron and zinc found in animal protein foods are more readily absorbed than the same nutrients from plant sources like rice and grains – an important consideration when selecting nutrient-rich complementary foods for infants.7

NURTURING IMMUNITY

Zinc and iron play an important role in an infant’s developing immune system.8 Introduction of foods that are a good dietary source of iron and zinc, like beef, early in life supports the growth of healthful bacteria in an infant’s gastrointestinal tract, which plays an important role in enhancing immune function.9, 10

1 American Academy of Pediatrics. Pediatric Nutrition Handbook. 7th ed. Elk Grove, IL: American Academy of Pediatrics; 2014. 2 Pan American Health Organization/World Health Organization. Guiding principles for complementary feeding of the breastfed child. Washington DC: Pan American Health Organization/World Health Organization; 2003. 3 Siega-Riz AM, et al. Food consumption patterns of infants and toddlers: where are we now? J Am Diet Assoc 2010;110:S38-51. 4 US Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory. USDA National Nutrient Database for Standard Reference, Release 28 (Slightly revised). Version Current: May 2016. Internet: http://www.ars.usda.gov/ba/bhnrc/ndl 5 Tang M, Krebs NF. High protein intake from meat as complementary food increases growth but not adiposity in breastfed infants: a randomized trial. Am J Clin Nutr 2014;100:1322-8. 6 Lozoff B, et al. Long-lasting neural and behavioral effects of iron deficiency in infancy. Nutr Rev 2006;64:S34-43; discussion S72-91. 7 Dewey KG. The challenge of meeting nutrient needs of infants and young children during the period of complementary feeding: an evolutionary perspective. J Nutr 2013;143:2050-4. 8 Chandra RK. Nutrition and the immune system from birth to old age. Eur J Clin Nutr 2002;56 Suppl 3:S73-6.

Visit www.BeefResearch.org for more research on Beef’s Role as a Complementary Food.

MO-AFP.ORG 47

Your health before

all else.

INTRO DU CING

You work hard to take care of your patients. The AAFP works hard to take care of you. AAFP Physician Health First is the first-ever comprehensive initiative devoted to improving the well-being and professional satisfaction of family physicians, and reversing the trend toward physician burnout. So you can stay passionate about your purpose: providing quality patient care.

Discover a wealth of well-being at

aafp.org/mywellbeing The AAFP Physician Health First initiative is made possible by your generous contributions to the American Academy of Family Physicians Foundation.

aafpfoundation.org