Missouri Family Physician: Mental Health Insights by mo-afp

FP

MISSOURI FAMILY PHYSICIAN

VOLUME 43, ISSUE 4

“During the interviewing process, CMH is highly unique in that they really strive to provide you with the job you want. They were able to tailor my contract to provide me with opportunities to broaden my skill set, which will allow me to continue to practice both clinical and hospital medicine. They are very open-minded and administration is willing to work with you. I feel well cared for and very appreciated at CMH, which is rare in an employer! I definitely feel that I made the right choice with CMH.”

Courtney De Souza, M.D.

Courtney De Souza, M.D.

Family Medicine

Joined CMH August 2023

Recruiting experts like you.

At Citizens Memorial, we’re more than just a healthcare provider—we’re a fully integrated system dedicated to delivering exceptional patient care. Many organizations may claim that, but CMH is different.

You can practice medicine here without the usual red tape and drama you might find in other healthcare organizations. Plus, you’ll be supported by a team of engaged, mission-driven physicians and patient care professionals who share your passion for making a meaningful impact.

Citizens Memorial Hospital is the perfect place to build a thriving medical practice while enjoying the natural beauty of the Ozark Mountains and surrounding lakes. We know you’re going to love CMH and southwest Missouri!

DONNA

SHELBY

DONNA SHELBY Director of Physician Recruiting

CONSTRUCTION IN PROGRESS

FAMILY PRACTICE OPPORTUNITIES

Highlights:

Opportunity to collaborate with advanced practice providers (APP)

Digital radiology in primary care clinics

On-site TJC moderate-complexity labs

Robust offering of specialists available on-site

Mental health services available in primary care

clinics, including LCSWs, psychologists, LPCs, school-based counselors, and psychiatrists

Mental health services available in primary care clinics, including LCSWs, psychologists, LPCs, school-based counselors, and psychiatrists

Clinic and System Staffing Resources:

> Outpatient Pharmacist

> Chronic Care Management

> Care Transitions: Central Scheduling and Nurse Triage Line

> Resources: Behavioral Health Counselors and New Diagnosis Care Coordinators

Director of Physician Recruiting

donna.shelby@citizensmemorial.com p 417-328-6273 | c 417-399-4333 citizensmemorial.com

ALYSON ANKROM

Physician Recruiter

ALYSON ANKROM Physician Recruiter

alyson.ankrom@citizensmemorial.com p 417-328-6238 | c 281-773-0777 citizensmemorial.com

> Care Coordinators for Referral and Prior Authorization

alyson.ankrom@citizensmemorial.com p 417-328-6238 | c 281-773-0777 citizensmemorial.com

FP

EXECUTIVE COMMISSION

BOARD CHAIR Kara Mayes, MD, FAAFP (St. Louis)

PRESIDENT Afsheen Patel, MD (Kansas City)

PRESIDENT-ELECT Natalie Long, MD (Columbia)

VICE-PRESIDENT Beth Rosemergey, DO, FAAFP (Kansas City)

SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS

DISTRICT 1 DIRECTOR Arihant Jain, MD, FAAFP (Cameron)

ALTERNATE Brad Garstang, MD (Kansas City)

DISTRICT 2 DIRECTOR Robert Schneider, DO, FAAFP (Kirksville)

ALTERNATE Vacant

DISTRICT 3 DIRECTOR Dawn Davis, MD, FAAFP (St. Louis)

DIRECTOR Lauren Wilfling, MD, FAAFP (St. Louis)

ALTERNATE Christian Verry, MD (St. Louis)

DISTRICT 4 DIRECTOR Jennifer Allen, MD (Hermann)

ALTERNATE Jennifer Scheer, MD, FAAFP (Gerald)

DISTRICT 5 DIRECTOR Amanda Shipp, MD (Versailles)

ALTERNATE Vacant

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

ALTERNATE Misty Todd, MD (Sedalia)

DISTRICT 7 DIRECTOR Chad Byle, MD, FAAFP (Kansas City)

DIRECTOR Jacob Shepherd, MD, FAAFP (Lee’s Summit)

ALTERNATE Rachel Hailey, MD, FAAFP (Lee’s Summit)

DISTRICT 8 DIRECTOR Andi Selby, DO, FAAFP (Branson)

ALTERNATE Barbara Miller, MD, FAAFP (La Russell)

DISTRICT 9 DIRECTOR Douglas Crase, MD (Licking)

ALTERNATE Vacant

DISTRICT 10 DIRECTOR Jenny Eichhorn, MD (Jackson)

ALTERNATE Vacant

DIRECTOR AT LARGE Stacy Jefferson, MD (St. Louis)

Krishna Syamala, MD, FAAFP (St. Louis)

Kento Sonoda, MD (St. Louis)

RESIDENT DIRECTORS

Noah Brown, MD, Mercy

Karstan Luchini, DO, MS, UMKC (Alternate)

STUDENT DIRECTORS

Mikala Cessac, UMC

Taylor LaVelle, UMC (Alternate)

AAFP DELEGATES

Peter Koopman, MD, FAAFP

Kate Lichtenberg, DO, FAAFP

Sarah Cole, DO, FAAFP Alternate Delegate

Jamie Ulbrich, MD, FAAFP Alternate Delegate

MAFP STAFF

EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE

ASSISTANT EXECUTIVE DIRECTOR Bill Plank, CAE

MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey

The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148

Website: mo-afp.org • Email: office@mo-afp.org

Reflections on My Leadership Journey Through Family Medicine

Pediatric Mental Health Guide

The Relationship Between Social Media, Mental Health, Relationship Wellness: A Literature Review

Promoting Physician Well-being in Addiction Care: Three Essential Strategies

Systematic Review of Perinatal Suicidal Behaviors Risk Factors

Advocacy Day 2025

2024 Summer Externs: Stories and Reflections from the Field

Transition to Practice Conference Prepares Students and Residents for Success

2024 Family Medicine Mixers Held Across the State

Physician Wellbeing Remains Critically Low; New Survey Unveils Impact of Healthcare Consolidation

Missouri’s Residents and Students Truly are Leaders in the Nation

Members in the News

Resident Composites

References

Annual Fall Conference Schedule

October 17, 2024

Virtual CME Series: Primary Care Dermatology in Skin of Color www.mo-afp.org/cme-events/virtual-cme/

November 7-9, 2024

32nd Annual Fall Conference and Annual Meeting InterContinental Kansas City at the Plaza www.mo-afp.org/cme-events/annual-fall-conference/

November 9, 2024

MAFP Commission and Board of Directors Meetings InterContinental Kansas City at the

February 25, 2025 MAFP Board of Directors Meeting Courtyard Marriott, Jefferson City (in-person & virtual)

MISSOURI FAMILY PHYSICIAN

Reflections on My Leadership Journey Through Family Medicine

Kara Mayes, MD, FAAFP Board Chair

St. Louis, MO

As my time as board chair of MAFP comes to an end, I have been reflecting on my journey of family medicine leadership.

After residency graduation in 2012, I joined Mercy’s residency program as faculty. Shortly after, I received an invitation to join the board of the St. Louis Academy of Family Physicians from my friend and colleague Dr. Sarah Cole. SLAFP was such a great experience from the beginning, with a focus on fellowship with other family physicians and encouragement of medical students considering family medicine as a career.

When a director position became available on the MAFP board, I jumped at the chance to get involved on a statewide level. It was my first introduction to state advocacy and I quickly attended all of MAFP’s conferences and events. Eventually, I became co-chair of the MAFP Education Commission and was able to help plan and improve our member education. The Annual Fall Conference has always been one of the highlights of each year for me. If you haven’t attended AFC recently - make sure to join us soon!

I have witnessed some incredible accomplishments during my time with MAFP. MAFP continues to be a leader in advocacy at the state and national levels. In the last couple years, we led the creation of a preceptor tax credit and helped obtain funding for additional residency spots across the state. Thanks to our Executive Director, Kathy Pabst, we worked with AAFP to develop a family medicine contest for high school students nationally through HOSA. This is helping students in Missouri (and across the country) learn about a career in family medicine. We made significant changes to our educational offerings in the past several years, particularly in 2020 when we adjusted to virtual education and figured out ways to continue to gather in person. And this year, we’ve been planning for Kathy’s retirement, ensuring MAFP continues to thrive in the future even without her expert guidance.

care. I found leadership opportunities at work as well, serving as an Associate Medical Director for Mercy’s primary care department in St. Louis. I discovered the joy of obesity medicine several years ago. The more time I spent helping my patients become the healthiest versions of themselves, the more I enjoyed my own practice. After much deliberation, I transitioned out of full-spectrum primary care to exclusively practicing obesity medicine. And this year I had another big transition as I left Mercy and became the Chief Medical Officer of Ilant Health, a brand-new company providing virtual obesity medicine.

THE MORE TIME I SPENT HELPING MY PATIENTS BECOME THE HEALTHIEST VERSIONS OF THEMSELVES, THE MORE I ENJOYED MY OWN PRACTICE.

As you consider your own leadership journeys, I have two main pieces of advice. First, seek out mentors and role models. Many of my opportunities in leadership have been available thanks to encouragement from previous leaders who saw potential in me. Second, say “YES!” as often as you can early in your career. When I got the invitation to be a board member on SLAFP, I didn’t really know what difference I could make. But it was that first “YES!” to SLAFP that led to a decade of opportunities. None of this would have been possible without the support of the incredible people around me. I am deeply grateful for the MAFP leaders who came before me (Sarah Cole, Jamie Ulbrich, John Paulson, and John Burroughs), the leaders who stand alongside me (Afsheen Patel, Beth Rosemergey, Natalie Long, Lauren Wilfling, and Lisa Mayes), and the dedicated MAFP staff. For the past 10 years, our Executive Director Kathy Pabst has kept MAFP running smoothly. Her guidance and leadership have made it possible for so many busy family physicians to step into leadership roles while continuing their busy practices. Kathy’s retirement at the end of this year is well deserved, and I know she’s going to make the most of it with travel and time with her grandkids, but she will be missed at the MAFP.

During this time, my own career has evolved many times as well. As faculty at Mercy Family Medicine Residency, I was able to practice full-spectrum family medicine with outpatient, inpatient, and obstetric

I also want to express my appreciation to my colleagues who have stepped in to cover when I’ve needed to spend extra time away from my patients. And of course, I would never have been able to be in this role without the support of my family. I will continue to be involved with the MAFP and hope to see many of you at the Annual Fall Conference in November!

Pediatric Mental Health Guide

Foster a supportive family environment: Encourage family members to support each other and work together to promote positive mental health and well-being in pediatric populations.

The state of pediatric mental health presents a significant crisis. According to the 1999 U.S. Surgeon General Report on Mental Health, 1 in 5 children in the United States grapple with mental illness. However, it is concerning that only half of youths in need of psychiatric services receive such care. Collaboration between primary care physicians (PCPs) and guardians is imperative to address this concerning disparity.1 Recognizing pediatric mental illness at early stages is of utmost importance, as evidence suggests that mental illness will emerge as one of the leading causes of morbidity and mortality.6

ANXIETY

Help children decide if their worries are realistic or unrealistic. Engage in flexible thinking. Encourage children to tolerate their anxiety, by remaining calm, and empathetic.6

MOOD DISORDERS

The most common mood disorder in children is depression, it manifests typically at age 14. It is pivotal to give frequent feedback on their social, academic, and behavior performance and develop a system where this information is shared amongst school and their guardians. Teach children how to set goals, and develop strong problem solving skills. Monitor whether the child has suicidal thoughts.6

ATTENTION DISORDERS

Attention disorders provide a combination or difficulty maintaining attention, hyperactivity, and impulsive actions. It is important to give clear, effective directions or commands. Develop routines, checklists and brain breaks for kids.10

TIPS FOR MENTAL HEALTH VISITS

As the pediatric mental health crisis continues to grow, primary care stands out as a crucial solution for addressing these issues.5 Research indicates that patients undergoing treatment for depression and anxiety in a primary care setting experienced a significant reduction in symptoms, partly attributed to the support and reassurance provided by their primary care physician5 However, despite feeling more comfortable discussing mental health concerns with their primary care provider, the stigma surrounding these issues often hinders patients from seeking care.6 Studies have demonstrated that a strong patient-primary care provider relationship reduces the likelihood of patients feeling stigmatized when seeking mental health care.7

Monica Aspra Rubi OMM Fellow Kansas City University

Grace Cooper OMSIV Kansas City University

DO

• Create a welcoming and supportive environment

• Advocate for better mental health resources

• Create more time to address mental health concerns

DON’T

• Continue to stigmatize mental health

• Address mental health concerns alone

• Approach these issues without accessing resources

training and endorse identifying behavioral health concerns, the interest in managing these concerns varies greatly with PCP’s.9 In a recent study, PCPs that were surveyed experienced an increased comfort with providing mental health assessments and referrals than providing direct interventions, even though there was difficulty in finding adequate resources for their patients.4 The fact remains that the lack of access and availability of mental health resources for children leads to PCP’s serving as the default mental health provider.4

TOOL KIT

There are many tools and resources available to primary care providers to help address behavioral health concerns in the pediatric population.

1. Mental Health Toolkit released by the AAP in 2007.2 This toolkit offers providers with invaluable resources to screen, recognize, address, and manage various mental health problems in children and

The Relationship Between Social Media, Mental Health, Relationship Wellness: A Literature Review

James M. Smith, PhD, LPC

SSM Health St. Mary’s Jefferson City

Lead Outpatient Therapist

Chrystal Smith, MEd, LPC

SSM Health St. Mary’s Jefferson City Outpatient Therapist

Prior to Facebook, the internet provided limited ability to communicate socially with peers. MySpace was an early social media platform, but quickly gave way to Facebook after Facebook’s founding in 2004. Since then, social media platforms have exploded exponentially, with the advent of Twitter (now X), Instagram, Snapchat, Tik-Tok, LinkedIn, and a host of others.

As early as the turn of the millennium, researchers were already interested in the influence of internet activity on people’s mental health. Bargh and McKenna (2004) were early researchers on the interaction between internet usage and social life. They identified that the amount of time spent on the internet was less of a factor on the effect that internet use had on the quality of a person’s social life than the study participants’ personal dispositions and the purpose of one’s activity. Sanders et al. (2000) were some of the earliest researchers exploring the relationship of internet use, depression, and quality of social relationships in adolescents. They found that internet usage and poor social relationships were correlated, but not internet usage and depression. They concluded, “These results do not imply directionality, as it was impossible to determine whether adolescents with poor social ties gravitated toward Internet activity or excessive Internet activity decreased social ties, or both” (p. 241). This lack of linear causation had not changed in the research done even in more modern times.

Research findings are mixed regarding the effect social media has on people’s personal mental health and the health of their relationships (Keles et al., 2020). For example, Valdez et al. (2020) researched the effect of social media on social connection and depression during the COVID-19 pandemic. They found that some people used social media to mitigate isolation, overcome loneliness, and depression symptoms, while others experienced worsening mental health, increased anxiety, depression, and felt more isolated despite similar levels of social media use. Valkenburg et al. (2022), in an umbrella review of research literature, found only weak associations between social media use and well-being across several mental health and relationship domains.

To understand the relationship between social media use, personal mental health, and relationship health, we decided to complete a literature review. Our research question originally was, “What is the effect of social media use on personal mental health and relationship health for baby boomers, Gen X, Gen Y, Gen Z, and millennial populations?” What we found surprised us.

METHODOLOGY

To answer our research question, we used a qualitative, thematic analysis method of literature review. We began by searching the GCU Library, Walden University Library, Google Scholar, Elicit, PsychInfo, and EBSCO Host using the search terms “social media,” “influence,” “effect,” “mental health,” “depression,” “anxiety,” “mental illness,” “wellness,” “distress,” “baby boomers,” “Gen* X,” “Gen* Y,” “Gen* Z”, and “millennials.” We began by including all research done since 2004, but eventually limited our inclusion criteria to only research done since 2014. We found that the research on social media and internet use has slowly but steadily increased year to year. We included all types of research including cross-sectional studies, experimental studies, and other literature reviews.

We used a qualitative, thematic analysis method, finding themes within the literature. We reached saturation of our thematic analysis after reading 55 articles. We recognized three themes repeated throughout much of the literature.

FINDINGS

To answer our research question, we completed a qualitative thematic analysis of research literature published in peer review journals since 2014. We included different types of research, including other literature reviews. We identified three themes that occurred consistently throughout the research, namely that the influence of social media was largely dependent on “Personal Dispositions,” “Content Engaged,” and “Time Spent.” We will discuss each of these independently.

PERSONAL DISPOSITIONS

We originally conceptualized our research, as is indicated by our research question, as an exploration of how social media use effects people across generational demographic divides. One of the first surprises we experienced while reviewing the literature is that demographics have little to do with the relationship between social media, personal mental health, and relationship health. It is personal dispositions, defined broadly to include resiliency factors, personality traits, mood states, fear of missing out, social pressure to maintain social media presence, attachment styles, loneliness, and other personal characteristics, rather than demographic differences (i.e. race, age, socioeconomic status, or other variables) that are correlated with the relationship between social media, mental health, and relationship wellness (Fox & Moreland, 2015; Konok et al., 2016; Reissmann et al., 2018).

Nesi and Prinstein (2015) found that adolescent students often use social media for social comparison and feedback-seeking behaviors. Personal characteristics of these students including self-confidence levels and social popularity mediated the relationship of social media use and depression. Students higher in self-confidence, better selfesteem, and who were more popular experienced less depression or anxiety than their peers with lower self-confidence, lower selfesteem, and were less popular despite similar levels of social media interaction. Social media and technology assisted communication served as either a vulnerability to or a protective factor against dating violence depending on personal characteristics like insecurity vs. security, jealousy vs. confidence in relationship, and others (Baker & Carreño, 2016).

Faelens et al. (2021) found that the association between personal dispositions of the tendency toward social comparisons, repetitive negative thinking, feeling insecure, and poor self-esteem and use of social media platforms was not unidirectional. These personal dispositions, rather, drove their participants’ engagement with social media, and the social media platforms exacerbated these tendencies. Hartman and Quick (2023) found that personal dispositions including attitudes, perceived norms, and fear of missing out influenced people to maintain social media use, even when the participants in their study saw their own social media use as problematic.

Dispositional factors also play a role in social media use that may threaten relationship health. Arikewuyo et al. (2021) found that

dispositional factors like lack of trust and emotional instability were exacerbated. Rather than easing lack of trust or emotional stability in the relationship, behaviors like snooping and electronic stalking became worse.

Bunker & Kwan (2024) studied the differences between one’s projected online persona (POP) and non-virtual face-to-face persona (F2FP) across several generations. Generational differences were not significantly related to differences between POP and F2FP. Across generations, there were small differences between POP and F2FP. People tended to view their POP more favorably than their F2FP. The more significant the difference in favorability between the two, the more significantly people felt a lack of well-being. This dissonance between who one can be online and who one is in person fostered both internal distress and heightened one’s anxiety in social situations, resulting in poorer relationship satisfaction.

One of the concerns that is often expressed among parents is how old should their child be before they give their children a cell phone (Vaterlaus et al., 2021). Personal characteristics such as dependability and conscientiousness were more highly associated with good outcomes of the introduction of cell phone use and social connection through media platforms that this facilitates than the age of acquisition. Vaterlaus et al. (2021) found that adolescents were often exposed to a catch-22 situation, in which not having a smartphone or social media presence increased their likelihood of experiencing bullying from peers, but having one and being on social media increased the probability of cyber bullying. Vaterlaus et al. (2021) recognized that personal characteristics, rather than age, were more strongly correlated with positive and negative experiences with cell phone ownership and social media use. They also recognized the danger of what we found as the second theme in the literature, Content Engaged.

CONTENT ENGAGED

Many researchers emphasized that it is content engaged in social media that has a significant effect in the relationship it has with personal mental health and relationship health. This theme of Content Engaged was reflected in two subcategories, type of content with which one engages and how one engages with the content.

Many older adults use social media, engaging content that involves family and friends. Chopik (2016) found that older adults, who suffered from mobility issues, experienced improvement in both their physical and mental wellness, when they were able to access and interact with peers and family members via social media. Baby boomers, who use social media for distraction, leisure, maintaining meaningful relationships, building new relationships, and church fellowship experience no negative mental or relational health from their social media use.

Unfortunately, social media use can wield devastating consequences to people’s lives when the content with which one engages is less wholesome. Van Ouytsel et al. (2018) found that individuals who perpetrate intimate partner abuse will often promote and receive risqué and malicious content to manipulate or coerce partners into submissive activities. On the flip side of this, college students who engage with social media content encouraging bystander intervention in situations of sexual assault expressed a higher intention to intervene if put in situations where they identified warning signs (Armstrong & Mahone, 2017).

How one engages can be as important in the relationship between social media use, mental health, and relationship health as the content one engages. Active engagement is normally understood as posting, responding, liking, disliking, and other means by which users express themselves. Passive engagement means scrolling, reading, or otherwise observing what is on social media without self-expression.

Valkenburg et al. (2022) found relationships between active and passive use and improved and compromised well-being. For example, people with depression may actively post on social media to evoke support from others, but their posts are focused on depressive experiences. People passively scroll past these posts, which then

exacerbates the depressed individual’s sense of isolation and increases depression. Van Der Wal et al. (2024) most clearly identified the relationship between adolescents’ personal dispositions and the content with which they engaged in social media. Adolescents’ motivations for using social media are homogenous, but their mood states when they begin an episode of social media use are not. Adolescents’ mood states determine the social media content with which they engage. The social media content, in turn, enhances that mood state (Van der Wal et al., 2024). Van der Wal et al. (2024) further found that time spent on social media becomes a factor for adolescents only when it begins to interfere with other important life activities. This speaks directly to the third theme that emerged from the research, Time Spent.

TIME SPENT

Several articles focused on how the amount of time spent on social media relates to people’s mental health and relationship wellness. Two subcategories emerged within this theme, how much time is spent on social media and when one spends their time on social media.

How much time people spend on social media has to do with several factors. Time spent on social media may be due to rumination, which is excessively reviewing, rehashing, discussing and speculating about perceived negative topics (Murdock et al., 2015). This is strongly correlated with poor mental health and disrupts relationships. Too much time on social media can lead to feelings and behaviors that mimic addiction symptoms, specifically excessive use, feeling panicked when one’s access to social media is compromised, and other people commenting negatively about one’s frequent use (Lapierre & Lewis, 2018). These signs of excessive time spent are stronger predictors of relationship disruption. People who are lonely are more likely to report dependency on social media than people who are not (Lapierre & Lewis, 2018).

Interestingly, Wilson (2018) found no correlation among older people between frequency of use and a sense of belonging, until their social media use became excessive measured in multiple hours per day. This suggests that there is a point of diminishing returns when it comes to amount of time spent. Like with older people, adolescents experience higher rates of depressive symptoms (i.e. anhedonia, poor self-esteem, and suicidal ideation) with excessive amounts of social media use (Twenge et al., 2018). These correlations do not imply a causal relationship wherein social media causes more depression, because participants in these studies were not screened for depression prior to the initiation of social media use.

Related to the time spent on social media is the idea of when one is using social media or on their electronic device. Hales et al. (2018) reported that people, who engaged in conversation in which their conversation partner responded to texts or social media alerts during the exchange reported feeling ostracized from their partner. Viola (2021) described a recreation of the “Still Face” experiment from the 1970’s using electronic devices. The “Still Face” experiment had parents engage with their children, then briefly turn away, and then turn back toward their children with no expression on their face and a refusal to engage their children. As a result, the children would escalate their attempts to re-engage their parents, then show various signs of distress, and then sink into a sullen, depressed state at the parents’ refusal to re-engage. Viola (2021) described that this experiment was repeated, but rather than having still face, the parents would attend to their electronic device rather than sit still-faced. The resultant behavior of the children mirrored that of the still face experiments, with the children escalating attempts for attention, becoming distressed, and then becoming sullen.

Viola (2021) went on to describe negative consequences of excessive time spent engaging in social media and electronic communication, including symptoms indicating addiction, depression, anxiety, and even physiological changes in the brain. Joshi (2022) found that cell phone and social media use, even that which created emotional arousal, were not significantly correlated to psychological well-being, but that participants would allow their cell phone social media use to disrupt their sleep (prevent them from going to sleep because they were on their phone), and that lack of sleep was disruptive to psychological well-being. Sleep disruption as a consequence of engagement with social media is correlated with multiple negative outcomes for adolescents in particular (Twenge et al., 2018; Van Der Wal et al., 2024).

These three themes, Personal Dispositions, Content Engaged understood as both type of content and how one engages, and Time Spent understood as both how much time and when one spends it, emerged throughout the research literature. These three factors interact with one another in such a way that make a linear, causal relationship impossible to verify. Rather, the relationship between social media use, mental health, and relationship health, should be understood as an interplay between these three factors.

DISCUSSION

The interaction of Personal Dispositions, Content Engaged, and Time Spent in the context of the relationship of social media, mental health, and relationship wellness is a self-perpetuating cycle, as is demonstrated in Figure 1.1. Personal dispositions, such as one’s mood state, personality traits, vulnerabilities to mental illness, resiliency factors, optimism or pessimism, political views, among many others, prime people regarding what content catches their attention and how they engage with this content. In this interaction, it is important to understand how social media AI algorithms process this.

Social media AI algorithms capture people’s interactions with the social media platform. The algorithms not only capture likes, shares, comments, and clicks that people do with their social media content, but it also captures people pausing on or scrolling past certain content. The algorithm captures that one spends 4 seconds reading this post but scrolled past that one. The algorithm amalgamates this information and then shows to people those posts that are most likely to evoke engagement from social media users. The more a person engages with certain content, the more of that type of content the social media AI algorithm shows them. This dynamic then increases the amount of time people spend with that specific type of content. Increased time with that type of content then reinforces whatever personal dispositions caused an individual to attend to that type of content in the first place. This interplay creates a spiral that could be upward or downward.

People with mental health, good self-esteem, strong social and emotional intelligence, and other resiliency factors will attend to content that is more positive, healthy, nurturing, and affirming. This in turn, due to the way the social media platform’s AI algorithms work,

will increase their exposure to this type of content. The more they are exposed to this content, the better they will feel.

People with mental illness, poor self-esteem, poor social or emotional intelligence, and with vulnerabilities to other harmful mental health threats will attend to content that is more pessimistic, unhealthy, depression, anxiety, or anger evoking, and compromising. This attention, spurred by their personal dispositions, will cause the AI algorithm to show them more content like this, increasing their exposure, and exacerbating their mental health and relationship challenges.

This has significant implications for people regarding both mental health and relationship wellness. For example, a father might deny his adolescent daughter’s request to go to her friend’s house on a school night. The daughter, upset about this, then posts on her social media feed that her “dad is a jerk.” The AI algorithm captures this and begins showing her content that frames dads as “jerks.” Her time engaging with his type of messaging increases, and her relationship with her father becomes strained, and the father is left with no understanding of what happened. A husband, who uses social media, begins looking at material posted about the “ideal” woman. He then begins to compare his own wife to these social media images, all the while fostering unrealistic expectations of her.

This interaction of personal dispositions has significant implications for personal mental health, too. A parent who is grieving the loss of a child might like a friend’s post on something that has to do with the friend’s children. The social media AI algorithm then begins to show the grieving parent more and more images of friends’ children, deepening the grieving parent’s own grief. A depressed client might post pessimistic thoughts as a way of trying to evoke support from people. Most people, however, scroll past these types of posts, so people do not like, respond, or offer support. This deepens the depressed social media user’s sense of emotional isolation, exacerbating the depression.

This has significant political and civic implications as well. A person may disagree with a particular politician’s proposed policies. The person then likes, shares, and posts their discontent with this candidate. The AI algorithm then shows the social media user more content about this particular politician or other content that support their own political inclinations. If the individual only gets their political information through their social media feed, then the individual is not exposed to any material that may challenge their own political beliefs. Progressive-liberal people only see progressive-liberal content. Traditional-conservative people only see traditional-conservative content. The consequence of this is a deepening polarization of political ideologies across a large population of people.

RECOMMENDATIONS

Recommendations for people whose social media use is problematic are not surprising. Given the interplay between personal dispositions, content engaged, and time spent using social media, helping people have a healthier relationship with social media, leading to improved mental health and relationship wellness is the key. Healthcare physicians already use a variety of instruments that assess for the personal dispositions that may be mental health vulnerabilities when social media use is mixed in. Depression, anxiety, social isolation, anger and bitterness and resentment, rumination, and other indicators of compromised mental health can continue to be monitored.

Adding to this, perhaps introducing questions about social media and electronic device usage would be helpful when screening for health. A physician could ask the individual how much time they think they are spending on their device, and then have the individual go into their device settings to see how much time is recorded by the device itself. Researchers throughout the studies reviewed found that people’s estimation of how much time they spent on the device was normally significantly less than the device settings themselves indicated, so having a valid and reliable scale to measure electronic device and social media usage is important (Araujo et al., 2017; Chen et al., 2022; Olufadi, 2016). When physicians suspect that social media use has become harmful to their patient, recommending less time spent is always appropriate.

Recommendations about when one uses their device or engages in social media use is important, too. Removing the device from sight completely when one is engaging in face-to-face conversations is correlated with richer, more empathic, and more satisfying personal interactions. Shutting off all social media notifications helps to reduce people’s consistent interruptions when in face-to-face communication.

Lastly, physicians can encourage people to control the content with which they engage. Due to the way social media platforms’ AI algorithms are designed, one’s social media feed can very quickly be taken over by content that is harmful to one’s psychological and relational well-being. Many people unwittingly foster anger, resentment, isolation, depression, anxiety, obsessive rumination, and a host of other threats to mental health and relationship wellness. It is also clear that content engaged can drive people’s behaviors (Armstrong & Mahone, 2017; Gall Myrick et al., 2020). Encouraging people to be mindful of the material with which they engage on social media can foster improved mental health and relationship outcomes.

CONCLUSION

We completed a literature review of research published in peer reviewed journals between 2014 to 2024 to explore the relationship between social media, mental health, and relationship wellness. The results were surprising. We found in the work of prior research that there is a complex interplay between personal dispositions, how and what content people engage on social media, and the time people spend on social media measured both as when and how much. These factors coalesce and can serve both as a harmful recipe that exacerbates vulnerabilities to mental illness and relationship disruption or as supportive, affirming practices that enhances wellbeing both personally and relationally. Physicians would do well to be aware of and assess for this complex interplay as part of a holistic health plan.

Authors Note: James M. Smith is the lead outpatient therapist at SSM Health St. Mary’s Hospital Outpatient Behavioral Health in Jefferson City, MO and a contributing faculty member with Walden University. Chrystala Smith is an outpatient therapist at SSM Health St. Mary’s Hospital Outpatient Behavioral Health and a doctoral student at Grand Canyon University. Lynette Mercado and Aleah Curley are doctoral students at Walden University and assisted in research for this article.

Promoting Physician Well-being in Addiction Care: Three Essential Strategies

More than 46 million individuals live with a substance use disorder (SUD) in the United States.1 As a result, family physicians frequently encounter individuals with SUD in their practice. Through growing evidence on treatment for common SUDs, family physicians are well-equipped to address these conditions and find resources and mentoring.2-4 However, awareness of self-care among family physicians treating is still lacking.

Unlike other chronic conditions such as hypertension or diabetes, family physicians cannot easily visualize progress toward their recovery of SUDs. For instance, we can observe objective improvements in blood pressure and HbA1c levels in patients with hypertension and diabetes, respectively. While urine drug screening (UDS) tests may provide some insights, they can only yield dichotomous results. Even if individuals reduce the amount or cut down on frequency of their substance(s) or change the route from intravenous use to intranasal use, the UDS results remains positive. Recovery from addiction often takes time as it typically develops over an extended period.

Furthermore, individuals with SUDs may face barriers to returning back to our clinic, including transportation or lack of health insurance, even if they initially show high motivation.5,6 This can lead physicians to blame themselves or feel guilty when their patients continue to use substances or do not retain in their care, eventually causing mental burnout. This article introduces three practical strategies to help family physicians maintain their wellness while taking care of individuals with SUDs.

Set appropriate expectations

Family physicians need to acknowledge that there are factors beyond our control, such as financial strain and influences of those surrounding individuals with SUDs although there are numerous ways for family physicians to support them. It is critically important to distinguish what we can do and what we cannot do, allowing us to effectively focus our energy and time on their needs.

For instance, a person with an SUD who was highly motivated to be sober a week ago may not show up for his follow-up appointment despite our best support. This can be disappointing, but we must remember that an SUD is a chronic condition that does not change overnight. We also need to admit our realistic impact on patients since

we only see a small part of their life during our encounter and do not know what is happening outside our facility.

I always emphasize to our patients the importance of coming back regardless of their progress towards recovery. I say something like “Please come back to our clinic no matter what happens. I can only help you if you come back. I am always here to support you. I truly hope that things go well, but even if they don’t, we can always start from wherever you are.” I have seen so many patients who did not come back as they feel ashamed of their continuous use despite our support, so this message can help them feel more comfortable coming back to our clinic.

Lastly, breaking their recovery process into smaller steps help us reaffirm patients’ actions and provide more accurate advice. For example, for those who inject fentanyl all day, every day, sobriety is a drastic change despite their desire to achieve it. If they change from injection use to intranasal use, that is certainly a progress, even if they are still using fentanyl. This harm reduction approach should be incorporated into our outpatient practice for the long-term benefit of our patients and ourselves.7

Maintain boundaries

While I emphasized the importance of a harm reduction approach when taking care of individuals with SUDs, maintaining healthy boundaries is equally important. Setting these boundaries for providing high-quality care. For example, if family physicians continue to refill medications even when patients have not followed instructions, patients may perceive that their actions have no consequences, negatively impacting the physician-patient relationship.

Holding off on refills of buprenorphine products can keep patients accountable especially if they keep missing their appointments or do not undergo urine drug screening tests at all despite multiple encouragements/reminders. Such decisions can be challenging for some family physicians due to fear of being blamed by patients. Developing an institutional policy can help mitigate this issue by providing a standardized approach, shifting any potential criticism from the individual to the institution.

Additionally, determining action plans prior to patient encounters can help guide difficult decision-making, preventing physicians from being swayed by emotional appeals for their requests, including refill requests.

Peer debriefing

While the internal mental mindset mentioned above helps family physicians mentally navigate difficult cases, peer debriefing is also invaluable. Addiction care often involves the art of medicine and an ambiguous decision-making process. Discussing complicated cases with colleagues not only enhance our clinical skill and also promote wellness by receiving validation and support for our actions and struggles from our peers.

Kento Sonoda, MD, FAAFP, FASAM, AAHIVS Saint Louis University Department of Family and Community Medicine

Systematic Review of Perinatal Suicidal Behaviors Risk Factors

McKenna Walsh, MA

Department of Medical Family Therapy

School of Medicine Saint Louis University

Jennifer Lauck, MA

Department of Medical Family Therapy

School of Medicine Saint Louis University

Dixie Meyer, PhD

Department of Medical Family Therapy

School of Medicine Saint Louis University

Rachel Livingston, MA

Department of Medical Family Therapy

School of Medicine Saint Louis University

Death by suicide in the perinatal population (pregnancy and one year postpartum) is growing. The Missouri Pregnancy Associated Mortality Review 2018-2020 Annual Report (2023) found that the number of suicide deaths doubled when comparing 2017-2019 to 2018-2020, with 18% of perinatal deaths attributed suicide. Metanalysis shows eight percent of mothers experience suicidal ideation during the first year postpartum. The purpose of this review is to examine risk factors for death by suicide in the perinatal population and to provide empirically recommendations to improve assessment and screening in healthcare. A systematic review of the literature from PubMed, Scopus, and CINHAL Plus was conducted, and our findings detected four major themes related to risk factors: Behavioral Health, Chronic Illness, Delivery and Pregnancy Outcomes, and Psychosocial Risk Factors. Based on our findings, we recommend medical providers seek to identify patients who are at a higher risk for death by suicide, to provide additional screenings for suicide, to recognize that screenings are fallible, to offer additional postpartum appointments for those at high risk for suicidality, to provide resources to patients if risks are identified, and to have clear plans for high-risk patients to access additional care.

Systematic Review of Perinatal Suicidal Behaviors Risk Factors

The perinatal period is a uniquely vulnerable time in a person’s life, often filled with significant changes. A recent meta-analysis noted suicidal ideation (SI)

incidence rates at 10% of pregnant persons and 7% of postpartum persons (Xiao et al., 2022). These findings may be surprising as children are often conceptualized as a protective factor against suicidality; however, stress, sleep deprivation, chronic pain, and relational destabilization are all associated with suicidal behaviors (Calati et al., 2015, Favril et al., 2023, Van Orden et al., 2010). In Missouri, a recent report indicated suicide deaths during the perinatal period doubled compared to the previous reporting period, and that 18% of all perinatal deaths are attributed to suicide (MO PAMR, 2023). For example, in the year 2020 alone, there were 85 deaths related to suicide (MO PAMR, 2023). A recent grounded theory may provide some insight into suicidal behaviors among perinatal persons (Biggs et al., 2023). Biggs and colleagues highlighted shame related to childhood trauma, gender-based violence, and mental health history as a primary factor in both suicidal and help-seeking behaviors. They further uncovered several themes in the types of shame experienced: the violation of expectations, disappearance of self, and psychological isolation, which can lead to the belief that death by suicide is the only option.

The purpose of this systematic review was to extend what is already known about suicide risks in perinatal populations. We sought to compile risk factors associated with suicide among the perinatal population via empirical evidence. This information aims to educate clinicians about suicidal tendencies within this vulnerable population, fostering an environment where they can destigmatize and normalize discussions about suicidal thoughts and behaviors (STB). We hope to empower patients to seek and embrace life-saving medical assistance by reducing stigma and shame. The goal of this review is to create a narrative synthesis to support medical professionals providing care to the perinatal population in the United States with an understanding of the complex risk factors for suicidal behaviors in the perinatal population.

Methods

A systematic review was conducted to examine the literature analyzing suicidality in perinatal populations. A protocol (see list protocol #CRD42024516827) was filed with the National Institute for Health and Care Research (PROSPERO) following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols standards (Page et al., 2021). Inclusion criteria were established using the Sample, Phenomenon of Interest, Design, Evaluation, and Research type Model (SPIDER, Cooke et al., 2012; see Table 1). We searched for articles that examined risks for suicidal behaviors (defined as SI, suicidal attempts, and death by suicide)

Sample

Phenomenon of Interest

Design

Evaluation Research

Type

Perinatal (pregnancy + one year postpartum) humans

Suicidal Behaviors include suicidal Ideation, suicide attempts, and death by suicide

Published literature of any research design, grey literature

The measure of suicidal Behaviors include suicidal Ideation, suicide attempts, and death by suicide

Qualitative, quantitative, and mixed methods peer-reviewed studies.

in the perinatal population (defined as pregnancy and one year postpartum). To validate the caliber of the research, all articles were published in a peer-reviewed journal. To account for differences across global experiences of the perinatal period and care, only studies in the United States were included. To reduce bias, we used a team-based approach, with at least two reviewers agreeing on the inclusion of all articles.

Searches, Data Extraction, and Planned Analysis

Searches were conducted by two members of the research team in April 2024. Three databases were searched: MEDLINE, CHINAL PLUS, and Scopus (including PsycINFO), using the dates January 1, 2004, through current. All searches included the terms “suicide” concurrently with “perinatal” using the “AND” Boolean search command. Limits included Humans, English, and All Journals. Results were managed using Mendeley, an electronic citation program. The search produced 232 results (MEDLINE = 34, CHINAL PLUS = 82, and Scopus, including PsycINFO = 116), 189 after duplicate removal. Studies were then independently screened for inclusion. Studies that did not have a relevant discussion of risk factors for suicidal behaviors in the United States perinatal population were removed. Articles that meet the initial search criteria were discussed in a team meeting to review eligibility and inclusion resulting in 19 articles selected for the review (See Figure 1).

Figure 1

Results

This review includes 19 articles representing findings across 11,849 patients and 2,585,406 electronic health records (EHR). Retroactive data collection was used in 7 studies covering all 2,585,406 EHRs and 10,618 patients through convenience sampling. For more information, see Table 2. Thematic analysis (Braun & Clark, 2006) yielded four major themes related to suicidal risks in perinatal populations, including Behavioral Health, Chronic Illness, Delivery and Pregnancy Outcomes, and Psychosocial Risk Factors.

Behavioral Health

Most articles (16/19) examined some aspects of behavioral health as a risk factor for suicidal behaviors. The results were then further divided into three subthemes: General Mental Health, Mental Health Diagnosis, Trauma History, and Suicidality, and Assessment and Continuity of Care.

Table 1

General Mental Health

Three articles reported any mental illness history was associated with suicidality (Kim et al., 2015; Tabb et al., 2013; Trost et al., 2021) with Trost et al. (2021) identifying the underlying cause of 11% of the perinatal deaths were attributed to mental health conditions. Kalmbach et al. (2021) found that women with nocturnal cognitive hyperarousal at baseline were at a greater risk for new-onset SI (31%) compared to low nocturnal cognitive arousal at (1%); the highestrisk women reported a combination of clinical insomnia combined with either nocturnal cognitive hyperarousal, or perinatal-focused rumination. Two studies found an association between SI and dysregulated cortisol slopes (Elrefaay & Weiss, 2023; Enătescu et al., 2020).

Mental Health Diagnosis, Trauma History, and Suicidality

Multiple studies identified a specific mental health diagnosis as increasing a patient’s odds of suicidal behaviors including a bipolar diagnosis (Battle et al., 2014; Byatt et al., 2018); a history of or current depression (Delker et al., 2023; Kim et al., 2015; Szpunar et al., 2019; Trost et al., 2021; Wilen & Mounts, 2006); anxiety (Delker et al., 2023); and a prior substance use history (Trost et al., 2021). Two studies (Gross et al., 2020; Szpunar et al., 2019) examined trauma history in the perinatal veteran population, and both found high rates of trauma and the need for trauma-informed care to improve access to mental health care.

SI is common postnatally (e.g., 3.8% and 1.1% of this subgroup at high risk for death by suicide; Kim et al., 2015). Lifetime SI intensity is related to postpartum depressive symptoms (Szpunar et al., 2019) including one’s suicide attempt history (Szpunar et al., 2019; Tabb et al., 2013; Trost et al., 2021; Vanderkruik et al., 2023) and their family history of suicide attempts or death by suicide (Vanderkruik et al., 2023).

Assessment and Continuity of Care

Identifying suicide risks may be key to prevention, yet there may be problems with perinatal behavioral health assessments (Newport et al., 2007; Tourtelot et al., 2020; Vanderkruik et al., 2023). Newport et al. (2007) found significant variance between the levels of SI endorsed by patients who completed both the Beck Depression Inventory (29.2%) and the Hamilton rating scale for Depression (16.9%), 33.0% endorsed SI on at least one of the rating scales while only 13.1% endorsed SI on both. Three studies found challenges in follow-up care after mental health screening (Tourtelot et al., 2020; Trost et al., 2021; Vanderkruik et al., 2023). For example, Vanderkruik et al. (2023) found that only 50% of the participants whose responses for SI triggered a safety protocol reported a change in treatment. Tourtelot et al. (2020) reported similar findings with only four out of nine participants who endorsed thoughts of selfharm had a documented discussion regarding their endorsement or a documented discussion of mood at the following visit. These findings are significant as Trost et al. (2021) found that in 421 patients who died by suicide, 39% had discontinued or changed psychiatric or SUD medications.

Chronic Health

Three studies found that there were medical comorbidities associated with suicidal behaviors, covering a patient population of 1280 patients from a mix of retrospective and mixed-method studies using convenience samples (Kreniske et al., 2022; Schiff & Grossman, 2006; Trost et al. 2021).

HIV-positive youth who had experienced pregnancy had 2.28 times higher odds of attempting suicide compared to other adolescents and young adults who had not experienced a pregnancy (Kreniske et al., 2022). Trost et al. (2021) found that unspecified chronic disease or illness was a significant contributing factor in 7% of suicide deaths.

Delivery and Pregnancy Outcomes

Harm to the birthing person and their baby may be associated with suicidality. Obstetric complications (Tabb et al., 2013) and severe vaginal lacerations may be associated with suicidality (Kim et al., 2015), but the research is inconsistent (Schiff & Grossman, 2006). Schiff and Grossman (2006) found risk for suicide attempts was highest in the 1st and 12th months post-delivery. Two studies found stillbirth and fetal death were associated with suicidal behaviors (Lewkowitz et al., 2019; Schiff & Grossman, 2006). Yet, other adverse infant outcomes, including preterm delivery, low birth weight, and congenital malformations were not associated with suicidal behaviors (Schiff & Grossman, 2006).

Psychosocial risks

Six articles discussed psychosocial factors that impact suicidal behaviors with two sub-themes emerging: Historically Marginalized Populations and Intimate Partnerships. Trost et al. (2021) identified a wide range of psychosocial factors related to death by suicide in the perinatal period, including a child protective services intervention or the removal of a child (found with 24% of those who died by suicide) and lack of social support and isolation (7%). At a systems level, 35% of the deaths by suicide were related to continuity of care, access or financial factors (15%), communication (8%), cultural or religious factors (27%), and social support or isolation (18%) contributed to deaths. Age may be related to death by suicide. Delker et al., 2023 found 18-34 to be the highest risk; and findings varied (i.e., Kim et al. (2015) mean 30.9 ± 6.2; Schiff & Grossman (2006) 15-24 (15-19 highest risk); Palladino, (2011) 45-54).

Historically Marginalized Populations

Findings from four articles showed discrepancies between the risk for suicidality and ethnicity. Trost et al. (2021) and Palladino et al. (2011) found that non-Hispanic whites were at a higher risk. Palladino et al. (2011) additionally found American Indians to be at increased risk for suicidal behaviors. Whereas in California, Delker et al. (2023) found that Black women were at the highest risk for suicidal behaviors. Kim et al. (2015) found that any non-white races had higher rates of SI compared to those who identified as white.

Three studies identified low SES (Delker et al., 2023; Kim et al., 2015; Newport et al., 2007) and having public insurance as a suicide risk factor (Delker et al, 2023; Kim et al., 2015). Other demographics related to an increased risk for suicidal behavior include non-English speaking and living in the U.S. (Kim et al., 2015), living in rural areas (Delker et al, 2023); and lower educational achievement (Newport et al., 2007; Delker et al., 2023).

Intimate Partnerships

Relational status and stability were found to impact the risk of suicidal behavior. For example, relationship instability was associated with an increased risk (e.g., unpartnered, Kim et al., 2015; unmarried, Delker et al., 2023). In contrast, Schiff and Grossman (2006) found that in Washington, 76% of deaths by suicide in the postpartum population were among married people. These findings may be explained by the other risk factors. Unplanned pregnancies were also associated with an increase in SI (Newport et al., 2007). Finally, Palladino et al. (2011) found that 54.3% of deaths by suicide involved documented intimate partner violence.

Discussion

Our findings reflect the complicated and nuanced reality of suicidal behaviors in the perinatal population. While the results generally fall within four major themes related to behavioral health, chronic health conditions, pregnancy and delivery outcomes, and psychosocial risk factors, many of these factors are not independent and are interwoven in patients’ lives. Beyond identifying the risk factors, addressing and improving patient outcomes are linked with the ability to implement appropriate levels of care.

Behavioral Health

Within the Behavioral Health theme, there were three identifiable subthemes: pre-existing mental health conditions overall, specific mental health diagnoses including trauma and SI history, and challenges with assessments and continuity of care. Most findings addressed mental health concerns. This may be because correlating SI and mental health concerns seem to be the most obvious link, but it also speaks to how care providers need to be attuned to and regularly assess for mental health concerns. Wilen and Mounts (2006) called for improved pre-pregnancy planning and counseling to target mental health care and preexisting mental health conditions are throughout the perinatal period. This is important as Byatt et al. (2018) found that obstetric providers often provide the bulk of medical care in the perinatal population highlighting the need for improved training in recognition, formal diagnosing, and referral to an appropriate level of care in the perinatal population. If birthing persons often discontinue their psychiatric medications during the perinatal period (Trost et al., 2021), including 90% of those with a history of SI (Howard et al., 2024), providers need to keep mental health at the forefront of care. Inquiring about mental health concerns may be key. Smith et al. (2004) found that providers identified a mental health concern in only 26% of patients with psychopathology and in only 12% of patients with SI. While postpartum care is often limited to one appointment, over a quarter of patients with a history of mental illness suffered a relapse in the first three months postpartum (Taylor et al., 2019). Thus, patients with a history of mental health concerns may need additional appointments to ensure care needs are met.

Chronic Health Conditions

The existence of physical comorbidities increases the risk of SI. Overall, chronic health concerns are linked to suicide risk. For example, those with HIV are at risk for suicidality. This risk is present for both parents during the perinatal period, regardless of if both partners have HIV (Kreniske et al., 2022). This is consistent with a rise in the literature addressing mental health concerns in fathers (Baldwin et al., 2018). While mothers have an opportunity to be seen by a healthcare provider, fathers may not have that luxury. For example, a growing number of pediatricians are assessing mothers for mental health concerns. These services may need to be expanded to fathers and other parents during infant wellness visits.

Pregnancy, Delivery, and Infant Outcomes

Pain is a well-documented risk factor for suicidal behaviors. Unexpected harm to the birthing person and their baby is related to SI (Kim et al., 2015; Tabb et. Al, 2013). Yet, planned physical trauma was not linked with increased SI, perhaps related to an increased sense of agency surrounding the physical trauma creating a sense of control which is linked with improved trauma outcomes (Schiff & Grossman, 2006). For example, previously planned cesarians likely had trauma informed planning for pain management and social support consistent with reduced SI (Procter et al., 2022). Non-fatal adverse infant outcomes, including preterm delivery, low birth weight, and congenital malformations were not found to be associated with SI (Delker et al., 2023; Kim et al., 2015; Schiff & Grossman, 2006). However, child death is a risk factor for increased SI (Lewkowitz et al., 2019; Schiff & Grossman, 2006). While SI was consistently found across the entire perinatal period (Lewkowitz et al., 2019 ), Schiff and Grossman found the risk for suicide attempts was highest in the 1st and 12th months post-delivery.

Psychosocial Factors

This review found, consistent with overall suicidal behavior literature (Brodsky et al., 2008; Mann et al.,1999), that marginalized populations (e.g., low SES (Delker et al., 2023; Kim et al., 2015; Newport et al., 2007); non-English speaking and living in the U.S.(Kim et al., 2015); living in rural areas, (Delker et al, 2023); lower educational achievement (Newport et al., 2007: Delker et al., 2023) were at a higher risk for SI. Marginalized populations are more likely to face adversity and stress. Adversity is one of the most significant and well-documented risk

factors for suicidal behaviors (Brodsky et al., 2008). Demonstrating the risk of unmanageable stress, a meta-analysis, using cortisol as a stress biomarker, noted individuals with higher cortisol levels were more likely to have SI (O’Connor et al., 2016). What may contribute to the SI risk is that our review also showed that protective factors such as relationships, when relationship concerns exacerbate instead of buffer stress, might also increase the risk for SI.

Some high-risk demographics (i.e., ethnicity, language barriers, rural community) may be more obvious than others, and other factors such as low SES may be demonstrated through insurance type. Thus, if medical providers are able to identify if the patient is at a higher risk for SI, then inquiring about current emotional states should be assessed, as well as discussing protective factors (supportive relationships) and what coping skills the patient utilizes. Providers may also need to develop plans with patients for when they are feeling hopeless, such as plans to report to an emergency room. Providers may also want to readily share hotlines such as the Suicide and Crisis Lifeline or the National Maternal Mental Health Hotlines for emergency situations.

Limitations

A significant limitation of the study of SI is the required sensitivity and inherent risk in working with the population. Much of the research is limited to observational retrospective studies, so verifying or identifying the causation of behaviors is challenging. We cannot know what other factors may contribute to self-harm, thus, there are probably other concerns missing from this review (e.g., shame, Biggs et al., 2023). The larger scale studies were conducted on EHR data and as such limited by the scope and quality of what is collected by an EHR system; yet, the studies where data was specifically collected to examine SI had small, convenient samples. There is a need for future research that is significantly powered and not a convenient sample to establish improved generalizability to the population. None of the studies included in this review were specific to Missouri. There may be cultural differences in Missouri or in different parts of Missouri that may also be risk factors specific to MO. To verify the relevance of our findings, research should be completed specifically in MO.

Points for Practice

Findings from this review demonstrate that while some patient factors seem obviously related to SI (e.g., previous history of SI, mental health diagnosis, child loss) other factors that put a patient at high risk for SI are less obvious (e.g., demographics, chronic health concerns, traumatic deliveries). Medical providers need to become well-versed in variables that are related to SI as well as the language that patients use that could indicate the patient is considering selfharm. For example, feeling hopeless and using language around hopelessness or language absent of a future may suggest a patient has SI (Wolfe et al., 2019). Providers should become comfortable directly asking about SI. Despite some assessments asking about SI, research shows patients may not answer honestly. Providers need to be familiar with behavioral health resources in their area so they are equipped to share this vital information with their patients regardless of the risk of suicide. MO HealthNet (Medicaid) for pregnant people covers mental health services and includes one year of postpartum coverage (MO HealthNet for Pregnant Women FAQs | Mydss.mo.gov, n.d.). Finally, patients may need additional well-being appointments postpartum if they are at high risk for SI. Connecting patients with counseling services may be necessary, especially if the patients have discontinued mental health medications for the pregnancy and postpartum period.

Conclusion

Providers and clinicians should be aware of the behavioral health, physical health, delivery, and pregnancy outcomes, and psychological risk factors that affect their patients’ risk for SI. Perinatal suicidal behaviors are a significant and modifiable risk; incorporating the findings of this review into better education, screening, and adoption into clinical practice, along with increased resources and support for the perinatal who report suicidal behaviors, would meaningfully impact the quality of care for the perinatal population in Missouri.

Authors Note: Correspondences concerning this article should be addressed to McKenna Walsh, email: mckenna.walsh@health.slu.edu.

ADVOCACY DAY FEBRUARY

MONDAY, FEBRUARY 24

6:00 – 8:30 p.m. – Virtual Advocacy Review

TUESDAY, FEBRUARY 25

8:00 – 9:00 am – Breakfast Buffet at Courtyard Marriott 9:00 am – 1:00 pm – Legislator Appointments

11:30 am – 1:00 pm – Luncheon Buffet at Courtyard Marriott 1:00 – 4:00 pm – MAFP Board of Directors Meeting (In-person/Virtual)

We encourage you to invite a colleague, medical student, or resident to join you to promote the importance of family medicine and primary care. This is your opportunity to educate your State Senator and State Representative on issues that affect you, your profession, and your patients.

Make your lodging reservation at the Courtyard Marriott, 610 Bolivar Street, Jefferson City, MO 65101, (573) 761-1400. Be sure to reference the Missouri Academy of Family Physicians to receive the discounted rate of $145 per night. The last day to make a reservation in our block is January 25, 2025. Any reservations made after that date are subject to availability.

Limited complimentary lodging is available with preference to residents and students. To request a complimentary room, email Bill Plank at bplank@mo-afp.org.

Questions? Contact MAFP by calling (573) 635-0830 or emailing office@mo-afp.org.

2024 Summer Externs: Stories and Reflections from the Field

The Family Health Foundation of Missouri (FHFM) and the American Academy of Family Physicians Foundation sponsored five medical students to participate in the 2024 MAFP Summer Externship Program. Because of your financial support, we can continue this program for medical students interested in family medicine each year.

Below are the stories about each of the externs’ experiences this summer. As you read each reflection, there is a common theme, continuity in care for your patients and full-scope family medicine. The medical students selected to participate in this year’s externship program are just a small example of the future family physicians in Missouri.

Ashvika Baskaran, OMS1

Kansas City University

Site: University Health

Kansas City Family Medicine

Residency

My month long experience as an extern at University Health - Lakewood was an invaluable learning opportunity. Every day, I had the chance to work alongside attendings, fellows, and residents to see and treat a variety of patients. I got to work in the outpatient and inpatient clinics, labor and delivery, and the maternal care clinic, all which exposed me to the various areas of family medicine.

Working with residents who were enthusiastic to teach was one of the highlights of my experience. I gained a wealth

of education, seeing in practice concepts that I had learned in lecture. Interviewing patients, observing procedures, and being a part of the healthcare team really helped me build my confidence in my exam skills and made my feel prepared for my upcoming rotations. Having real conversations with patients reminded me of the humanity and compassion in medicine, which is easy to forget when you are in a classroom, and it reignited my excitement for being a physician in the future.

Throughout this month, I gained a deep appreciation for family medicine and its significant impact on people’s lives. I interacted with many patients who expressed such gratitude to their residents for the real lifestyle changes they helped them achieve. I heard stories of patients working with their doctors over years to reduce their blood pressure, manage their weight, and make long-lasting lifestyle changes that ultimately changed the course of their lives. I enjoyed the flexibility that family medicine gives you to meet your patients where they are and to make small changes at a time because you know your patient will be back to follow up with you soon. It emphasized the importance of family physicians as the first line of defense and cornerstone of medicine.

I’d like to extend my thanks to MAFP and the entire team at UH Lakewood for this opportunity to learn more about family medicine and get a glimpse into what my future career could look like.

Isabella De La Torre, MS1

Saint Louis University Site: SSM Health/Saint Louis University Family Medicine Residency

I am very thankful to the MAFP and SLU’s Family Medicine Residency Team for giving me a much greater appreciation for family medicine. For four weeks, I worked with the team at the Family Care Health Center in Carondelet. Through this experience, I had the opportunity to shadow their physicians, conduct patient interviews, observe and participate in procedures, and learn through their didactic periods.

The Family Care Health Center serves primarily uninsured and underinsured patients, which brought an even deeper meaning and appreciation to my experience. Health is so much more than how our body functions, but it is composed of where we live, where we work, what language we speak, what support we have, what biases we carry, and so much more. These patients all came from places and backgrounds which have influenced their health to what it is today. Whether it is an immigrant who wants mental health services, a woman who has faced trauma and abuse, or a child who needs extra support at school, each individual has their own story with their own struggles and their own needs. At the Family Care Health Center, I listened to these stories, and I watched the physicians use these stories to provide better care. These providers truly took the time to get to know their patients and ask them about their lives, their transportation, their families, and what support they need. This was something I knew I appreciated about family medicine - their ability to think wider than a single diagnosis - but to see it being done made me prideful. To see a physician making the time to see a patient who was 30 minutes late, offering their patients compression socks or some diapers so they don’t need to use their own money, trying to get their patient a same-day chiropractor appointment so they don’t need to take off work again - it all made me hopeful. Hopeful for my patients and hopeful for the change that a family medicine physician can make.

I am happy to say that this experience has reminded me why I am passionate about medicine. It’s not because of the procedures or the knowledge or the money, but for the patient connections that I saw during my externship. It’s for the moments of shared joy and laughter with a family you’ve been seeing for the past 20 years. The moments of despair when there has been a death and a hardship burdening your patient. It’s the holding of your patient’s hand or the touch of their shoulder to let them know that you are there for them, that you support them, and that you will take care of them. These are the moments that impassion me to pursue medicine. And these are the unique moments that family medicine gets to experience everyday; they have the privilege to create these connections. Through my externship, I got to experience all these emotions, and I am so thankful I did. I know that I will be ready for my clerkships, and I will lead with compassion, empathy, and a drive to be the best provider I can be, because that is what our patients deserve.

Maaya Dev, OMS1

Kansas City University

Site: Research Family Medicine Residency

I am so grateful for the month I spent this past summer as an extern at Research Medical Center! I did two weeks of outpatient clinic, one week of inpatient hospital service, and one week of inpatient OB. It gave me a great taste into the diverse opportunities available in family medicine and the general flow of a rotation in the field. I loved being able to connect with patients and apply the knowledge I gained during my first year of medical school. It gave me great clinical experience that’s already helped me in second year and will continue to help me when I start rotations.

During the outpatient clinic, I enjoyed seeing the different approaches all the physicians and residents took and observing the diversity of patients and conditions. I saw everything from joint injections to pediatric well child visits. I took histories and did physical exams and got to present the cases to the physicians who gave me great constructive feedback. My weeks in inpatient hospital service and OB were my first times in both settings. The residents were very open to teaching me and I’m glad I was able to have my first inpatient experiences in such a learning environment.

I followed many differing patients throughout the week in inpatient hospital service, and I was able to see deliveries and a C-section during OB! Additionally, learning more about the patient population in Kansas City helped me feel more connected after moving here for medical school, and it helped motivate me during my second year!

Thank you to MAFP, AAFP, and FHFM for sponsoring such a great opportunity. I am also thankful to Dr. Arabindoo and the Research Medical Center Family Medicine Program for being so welcoming and willing to teach.

Meghana Mettu, OMS1

Kansas City University

Site: Freeman Kansas City Family Medicine Residency

I want to express my heartfelt gratitude for the invaluable opportunity to shadow the doctors at Freeman this summer. The experience has significantly deepened my understanding and appreciation of family medicine, and I am profoundly grateful for the knowledge and insights I gained.

Some of my favorite moments that have further ignited my passion for family medicine include:

• Before walking into a patient’s room, who had been suffering from anxiety, depression and an eating disorder, Dr. Upagya confidently said, “I know I can help this patient.” Witnessing such dedication was incredibly inspiring.

• When Dr. Miller decoded the reason for the visit of a patient who could only respond with “yes/no” answers and was

unable to speak or write down his thoughts, it seemed like an endless game of charades. Yet, within five minutes, Dr. Miller cracked the code and discovered the patient needed his medication refilled. Her perseverance and skills were remarkable.

• Dr. Brandyce shared her experience of being a lawyer and the intersection of law and medicine over lunch. It was fascinating to learn how the minds of a lawyer and a doctor are more similar than I had imagined.

• Dr. Kelly taught me about the various services offered to patients and demonstrated how doctors can adapt a holistic model of medicine by addressing social determinants of health. He educated me about local programs that give patients access to medical equipment they can borrow and free transportation for those who may not be able to afford it.

• Dr. Akhtar’s patient wanted a picture with her and expressed how much she would be missed when she leaves. It was a touching moment that highlighted the profound impact of a compassionate physician.

• At the MAFP Transition to Practice conference in Springfield, MO, Dr. Pelate patiently taught me how to insert an IUD, which led to a thought-provoking conversation about how to discuss sensitive matters such as birth control and family planning for people of different cultural backgrounds.

• Dr. Yoshi taught me how to properly collect a patient’s history and the importance of clarifying terms like “dizziness” vs feeling “lightheaded”. He emphasized that in medicine, the details are just as crucial as the big picture.

• Dr. Kulasekera showed me a plethora of things I didn’t know that fell under the realm of family medicine such as Pap smears and knee injections. Shadowing him revealed the extensive responsibilities of family medicine doctors.

• Dr. Morris taught me how to counsel patients on managing their diet beyond just recommending certain foods. He explained that weight management involves considering aspects such as: working conditions, access to fresh food, and personal motivations.

Everyone has taught me the true value of “family” in family medicine. I would like to thank each and every one of them for being so patient and kind to me during this time. I learned so much information that I would not have learned in a classroom setting. I hope to carry these precious memories with me for the rest of my life and they will inspire me to be a great physician that patients love and respect.

There was never a dull moment in the clinic. I felt like I was always learning, and I truly think Missouri is lucky to have such compassionate and passionate physicians.

Vivian Tran, MS1

Saint Louis University

Site: Mercy Family Medicine Residency

This past summer, I had the privilege of participating in a Family Medicine Externship through MAFP where I was placed at Mercy Hospital in St. Louis. During the externship, I had the unique opportunity to

shadow various family medicine physicians at Mercy. The typical experience includes four weeks of in-person shadowing in a clinic and hospital. Due to unforeseen circumstances, my planned experience required some adjustments. However, through the kindness and patience of the family medicine physicians and staff, I was able to make the best out of my experience despite the circumstances. I had the opportunity to work on a capstone project in a field I was passionate about – access to healthcare services in immigrant communities. In addition, I also was able to go in and shadow some physicians for a week and observe a wide range of patient encounters.

For the capstone project, I focused on developing a flu shot, mammography, and blood pressure screening booth that would be hosted at a local Vietnamese community fair in St. Louis. I would like to thank Dr. Sarah Cole and the mammography staff for their patience and guidance in helping me develop the project from a small idea to a multifaceted booth where I could potentially address significant health needs within the Vietnamese community in St. Louis. Additionally, I was guided on how to properly make vaccine and consent modules as well as how to fill out IRB forms for documentation and approval from my medical school.

In the clinic, I observed a wide range of patient encounters –from routine screenings to procedures including removal of basal cell carcinomas and Nexplanon placement. I also appreciated the opportunity to observe the physicians and residents provide reassuring care and patient comfort. One experience that stood out to me was helping a patient feel comfortable during a minor procedure. Although the patient spoke English, she was understandably nervous. By communicating with her in Vietnamese, I was able to provide comfort and support by creating a more relaxed atmosphere for both the patient and the resident physician. This experience highlighted the importance of cultural patient care and reinforced my desire to serve diverse immigrant communities in the future.

I enjoyed the patient encounters in the clinic and how family medicine offers the ability to build long-lasting relationships with your patients through providing longitudinal care for a variety of conditions. The diversity of care provided numerous learning opportunities ranging from diagnosis of POTS to managing hypertension and conducting well-baby checks. The attendings and residents I shadowed were passionate about the program and felt well-supported throughout their residency. Each attending and resident had their unique approach to patient care, which encouraged me to reflect on how I will interact with patients in the future.

Throughout the externship, I am deeply grateful for the support and guidance that Mercy’s Family Medicine Residency provided for me. This externship further strengthened my desire to pursue a career in family medicine and hopefully serve the community I will one day be a part of. I would like to thank Dr. Sarah Cole, Dr. Stefanie White, Ms. Zoe Burton, and the entire Family Medicine Residency program for their kindness and mentorship throughout my time at Mercy.

Transition Conference Prepares Students and Residents for Success

The MAFP and the Family Health Foundation of Missouri (FHFM) hosted the Transition to Practice conference for family medicine residents and students again this year. Held on June 21-22 at Oasis Hotel and Convention Center in Springfield, this conference included hands-on procedures and sessions to help 15 medical students choose family medicine and 11 current residents become better family physicians.

Following lunch and introductions on Friday, the conference started with an opening session from Misty Todd, MD, on her journey from the Family Farm to Family Medicine and the impact one physician can have on a community. Breakout sessions for residents and students targeted specific areas of interest to them. Students gained insights and were able to ask questions in an informal setting with Residency Directors Misty Todd, MD MD (UMC Bothwell FMR); Barbara Miller, MD, FAAFP (Freeman FMR); and Lawrence Gibbs, MD, MSEd, FAAFP (Lee’s Summit Medical Center). Residents were able to engage with Heather Rooney McBride, JD to discuss key considerations when negotiating their employment contracts.

Following the breakout sessions, the group received Practical Finance Tips the Professionals Never Tell You from Kelly Dougherty, MD, PGY2 and a session from Kathy Pabst, MBA, CAE, MAFP Executive Director focused on Professional Development for Family Physicians and the career growth available outside of the clinic. The evening concluded with a Family Medicine Mixer sponsored by CoxHealth that featured pizza, wings, golf, and networking at BigShots Golf.

Saturday morning started with a talk from Lauren Wilfling, DO and Charlie Rasmussen, DO titled “Putting the Family in Family Medicine” where they discussed strategies each of them have utilized to balance active practice and family life in their own respective families. Drs. Wilfling and Rasmussen were then joined by Barbara Miller, MD, FAAFP and Beth Rosemergey, DO, FAAFP to provide a panel discussion to shed light on their varied practice settings. The panel explored rural medicine, multisite full-spectrum care (including emergency departments), academic medicine, and as an employed physician.

Barbara Miller, MD, FAAFP; Mariam Akhtar, MD, and some of the residents from KCU-GME Consortium, Freeman Health System led an interactive practice workshop on joint injections and implantable contraception. All students and residents were able to practice these common and important in-office procedures in a relaxed learning environment.

The conference wrapped up with the Missouri Mingle reception. Exhibitors promoted their residency program, health facilities, and learning opportunities to all attendees. This was an opportunity to meet with and learn more about residency and employment options in Missouri.

Financial support for this program is provided by the FMPC which is funded by members like you! Help programs like this continue to support family medicine by giving to the FMPC. Select “Chapter Grants” when making your gift online at https://www. aafpfoundation.org/donate.html. Thank you.

Many thanks to our sponsors, without whom this conference would not be possible. The Family Health Foundation of Missouri, Missouri Health Professional Placement Services, Mercy, Freeman Health Systems, and CoxHealth.

2024 Family Medicine Mixers

We were excited to offer opportunities for Family Physicians from around Missouri to socialize in fun, relaxed settings over the summer. Each of these evening Family Medicine Mixers were open to members and their families as well as prospective members. We had 73 total registrations split between all 4 locations. All had a great time and enjoyed socializing with fellow family physicians outside of the clinic.

June 21, 2024

BigShots Golf, Springfield Sponsored by CoxHealth

The 2024 Transition to Practice Conference was held in Springfield this year. One of the highlights of that conference is the connections made possible by a fun evening out with our students and residents. This year, practicing family physicians and their families joined this bright group of future doctors at BigShots Golf. Attendees were able to enjoy some pizza, chicken wings, drinks, and a beautiful evening outside. All in attendance were able to share several bays MAFP had reserved and play golf games at their leisure.

June 21, 2024

BigShots Golf, Springfield Sponsored by CoxHealth

July 31, 2024

Kansas City Zoo

July 31, 2024

Kansas City Zoo

June 21, 2024

BigShots Golf, Springfield Sponsored by CoxHealth

July 31, 2024 Kansas City Zoo

Family physicians from around the Kansas City area were treated to dinner adjacent to the Polar Bear exhibit and looking into the 140,000-gallon pool. Although Nuniq the Polar Bear was very active earlier in the afternoon, he decided to retire to his air-conditioned den and escape the hot evening air. Following a warm welcome and introductions from MAFP President, Afsheen Patel, MD, our members enjoyed a delicious taco bar, drinks, and fellowship with one another.

August

20, 2024

St. Louis Zoo

September

10, 2024

Canterbury Hill Winery, Jefferson City Sponsored by SSM Health

Family physicians from around Central Missouri gathered on the patio at Canterbury Hill Winery overlooking the Missouri River Valley for dinner, wine, and conversation. This group exemplified family medicine as some members brought their children, and a few medical students and residents from University of Missouri-Columbia joined us. MAFP Past President Darryl Nelson, MD and his wife Jo, even flew in from Kansas City to enjoy the evening and scenery.

Physician Wellbeing Remains Critically

Low; New Survey

Unveils

Impact of Healthcare Consolidation

Urgent Need for Solutions to Improve State of Current and Future Physician Wellbeing

The Physicians Foundation recently issued data showing that the state of wellbeing remains critically low for physicians, with healthcare consolidation exacerbating the issue. Its latest survey, 2024 Survey of America’s Current and Future Physicians, unveils the urgent need to improve physician wellbeing and center physicians’ perspectives in today’s rapidly evolving healthcare landscape. In recognition of last month’s National Physician Suicide Awareness Day (NPSA Day), The Physicians Foundation and The Dr. Lorna Breen Heroes’ Foundation call for systemic change through Vital Signs: The Campaign to Prevent Physician Suicide to improve the wellbeing of current and future physicians.

Key Findings from the Report:

• Six in 10 physicians and residents, and seven in 10 medical students reported often experiencing burnout

• More than half of physicians know of a physician who has ever considered, attempted or died by suicide

• Medical students (49%) are significantly more likely than residents (33%) and physicians (18%) to have sought medical attention for a mental health problem

• Seven in 10 physicians and medical students, and at least six in 10 residents agree that consolidation is having a negative impact on patient access to high-quality, cost-efficient care

• According to physicians, negative impacts of mergers/ acquisitions include job satisfaction (50%), quality of patient care (36%), independent medical judgment (35%) and patient healthcare costs (30%)

• Safeguards for consolidation identified by physicians, residents and medical students include preserving physician autonomy (90%), maintaining patient standards (87%), increasing transparency and disclosure (86%) and assessing long-term impact (84%)

“Across the nation, the overall wellbeing of physicians has a profound impact on their professional lives and the quality of care they can provide to their patients,” said Gary Price, MD, president of The Physicians Foundation. “Even before the pandemic, physician wellbeing was in jeopardy; now, the rapid pace of healthcare consolidation is further deteriorating the practice environment. As changes to the healthcare landscape increasingly restrict physicians’ autonomy to care for their patients, it is imperative that we implement solutions now. On this National Physician Suicide Awareness Day, we urge everyone to join us in our mission to support physicians and ensure our healthcare system’s strength and sustainability for the future.”

To read the full story, visit their website: https:// physiciansfoundation.org/research/examining-physician-residentand-student-wellbeing-and-impact-of-the-current-healthcarelandscape.

Missouri’s Residents and Students Truly are Leaders in the Nation

The AAFP’s National Conference for Family Medicine Residents and Students buzzed with excitement as members of the Missouri Academy of Family Physicians campaigned for national leadership positions. You could feel the energy as our future family physicians shared their visions for family medicine and the Academy. Missouri’s alternate resident and student board members were elected during this three-day conference, which took place July 31 to August 2 in Kansas City.

Leading up to the National Conference, the MAFP hosted a virtual meeting for residents and students interested in leadership roles. Past candidates and elected members shared invaluable insights on running a successful campaign, helping to empower the next generation of leaders.

In addition to the excitement of the elections, Missouri’s residency programs and recruiters showcased their offerings along Missouri Street in the exhibit hall. This year, Missouri Street was strategically placed near the Midwest Lounge, giving attendees easy access to explore our programs, organizations, and the many opportunities our wonderful state has to offer.

Several students and residents successfully campaigned for AAFP leadership positions:

• Payal Morari, OMS3, University of Missouri Kansas City was selected as the student alternate delegate to the AAFP Congress of Delegates. She will serve as the student delegate in 2025.

• Mikala Cessac, MS4, University of Missouri – Columbia, was elected as the student member on the AAFP Board of Directors.

• Kelly Dougherty, MD, PGY2, Mercy Family Medicine Residency, was re-elected to serve another term on the AAFP Foundation as the resident delegate.

This year, Missouri was represented at the conference by Tiffany Chen, MS4 from Washington University in St. Louis, and Hannah Boehler, PGY1 at CoxHealth Family Medicine Residency in Springfield. Our delegates voted on behalf of the MAFP on crucial issues, including Medicare expansion, support for rural training for students and residents, addressing adverse childhood experiences, obesity healthcare, intimate partner violence, alcohol consumption safety, substance use disorder treatment, and many other significant healthcare topics.

Tiffany Chen, representing Missouri’s medical students, reflected on her experience: “The AAFP conference was life-changing for me. Being at a medical school without a family medicine department, it was inspiring and motivating to have the opportunity to meet with different programs across the country and see the great impact that family medicine has as a specialty. As the Missouri student delegate, I also had the privilege of representing students in family medicine and using my voice to contribute towards improvements and advancements in the specialty. I am truly grateful for the opportunity to attend this conference and highly recommend it to any students who are interested in family medicine.” Note: insert her headshot by quote. The Missouri Academy hosted a reception during the National Conference to bring together our residents and students, along with residency programs and their teams, for an evening of networking, comradery, and a little business. Residents and

students elected their incoming alternate directors on the MAFP board at this event.

This year’s alternate board members are:

Taylor LaValle, MS2, University of Missouri - Columbia

Karstan Luchini, DO, PGY2, University of Missouri - Kansas City

The former alternate directors will transition to director positions for the next 12 months: Noah Brown, MD, PGY2, Mercy Family Medicine Residency, St. Louis

Mikala Cessac, MS4, University of Missouri – Columbia

A big thank you to Kelly Dougherty, MD, from Mercy Family Medicine Residency, and Abby Crede, MD, from the University of Missouri Kansas City School of Medicine, and the University of Missouri – Columbia Family Medicine Residency, for your dedicated service as past MAFP Directors.

Mikala Cessac, an MAFP Student Board Member, attended the conference as she begins her leadership journey: “My involvement with MAFP has provided me amazing opportunities that I would not have imagined for myself a few years ago. During my first National Conference, I attended the Missouri Reception and became involved with MAFP as a student alternate on the Board. From that time, I have been able to meet and network with family physician leaders from all over the state and gain new knowledge and perspective on the technical aspects of how a large Academy functions. Additionally, I have been able to further my involvement on a national level with the AAFP, first serving on a Commission and currently on the Board of Directors. These experiences have been incredibly valuable to me as they have provided the opportunity to advocate for the needs of medical students and family physicians, create relationships with physicians from across the nation, and help influence the direction of one of the largest medical organizations. My involvement with AAFP would not have been possible without MAFP and the incredible physicians and staff who have kindly encouraged and taught me many things along the way. I encourage any student with any involvement level to attend an MAFP event, as you will be welcomed and supported immensely.”

Next year’s conference will be renamed AAFP FUTURE 2025 and will take place from July 31 to August 2, 2025. Missouri’s resident delegate will represent Research Family Medicine Residency, while the student delegate will come from AT Still University in Kirksville. Delegates are chosen on a rotating cycle, which can be found on the MAFP website.

MEMBERS IN THE NEWS

Laura Morris, MD: Mizzou’s Vaccine Expert and Mentor in Family Medicine

Laura Morris, MD, MSPH, FAAFP, was featured in a recent AAFP News’ #FamilyDocFocus titled “Mizzou Mentor Found Her Niche as Vaccine Expert.” You can read the article online at https://www. aafp.org/news/family-doc-focus/laura-morris. html.

AAFP News’ #FamilyDocFocus spotlights practicing family physicians, FPs in academic or administrative roles, family medicine

residents, and medical students committed to the specialty who have dedicated themselves to improving the lives of their patients and communities.

Dr. Morris is the Associate Program Director of the University of Missouri’s Family and Community Medicine Residency and Professor of Clinical Family and Community Medicine. She is also a Medical Education Director of MU-Area Health Education Centers.

Dougherty Recognized as National Leader

Kelly Dougherty, MD, a Missouri member, was among recipients of the American Academy of Family Physicians’ (AAFP) Award for Excellence in Graduate Medical Education. Her performance during residency training ranked her among the top family medicine residents in the country and her hard work is recognized by the AAFP Commission on Membership and Member Services. Dr. Dougherty will receive a $2,500 scholarship from the AAFP, sponsored by the AAFP Foundation, that recognizes outstanding family medicine residents for leadership, civic involvement, exemplary patient care, and aptitude for and interest in the specialty. Additionally, these two outstanding physicians will be recognized during FMX this fall for their marvelous achievements.

In addition, Dr. Dougherty was reappointed to serve on the AAFP Foundation Board of Trustees as the Resident Representative. The mission of the AAFP is to improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity. It is through the hard work of dedicated members like Dr. Dougherty that they are able to accomplish their goals.

Congratulations Dr. Dougherty!

CoxHealth FMR Launches Lifestyle Medicine Interest Group

CoxHealth Family Medicine Residency, one of two programs in Missouri to offer the Lifestyle Medicine Residency Curriculum (LMRC), recently started a Lifestyle Medicine Interest Group. The group is co-led by Melanie Kim, DO (PGY3) and Erica Casey, MD (PGY2). At the first meeting, a whole food, plant based lunch was provided to promote the delicious, accessible nature of such a meal. Research shows that intensive lifestyle change, primarily focused on a whole food, plant based diet, can control and even reverse diabetes more effectively than first line medications and “traditional” lifestyle recommendations. However, many physicians are skeptical about recommending such a diet because they have not experienced it for themselves. By providing a delicious meal within this eating pattern, it was demonstrated how enjoyable and unrestrictive this eating pattern can be.

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Morari Elected as Student Alternative Delegate

MAFP student member Payal Morari was elected to serve as student alternate delegate and delegate to the American Academy of Family Physicians Congress of Delegates. Payal is a student at Kansas City University College of Osteopathic Medicine. Her leadership term began at this year’s Congress of Delegates on September 23-25 in Phoenix, AZ, where she served as alternate delegate, and will run through the 2025 Congress of Delegates October 4-6 in Anaheim, CA, where she will serve as delegate.

Congratulations, Payal!

Cessac Elected to Serve on AAFP Board

Mikala Cessac was elected to serve as student member of the American Academy of Family Physicians Board of Directors. Her term began at this year’s Congress of Delegates on September 23-25 and will run through the 2025 Congress of Delegates October 4-6, 2025, in Anaheim, CA.

Mikala is a student at the University of Missouri Columbia School of Medicine and serves as the MAFP Alternate Student Director. Congratulations, Mikala!

Smith Organizes FMIG at CoxHealth FMR Committee Interest Group

Michelle Smith, MD, PGY3 and CoChief at CoxHealth Family Medicine Residency has organized a Family Medicine Interest Group as part of her scholarship project. The group will host a handful of events throughout the year, which will include a discussion on a topic chosen for local medical students, plus free food and/or a free fun activity. The goal is for medical students to learn more about medicine, decide whether or not FM is the right fit for them, get tips on residency from residents themselves, and network with other students/residents/faculty/FM doctors, all while also having fun. The first meeting was held on September 30 at Classic Yard, with a discussion led by Kyle Griffin, MD (CoxHealth FMR faculty), followed by pickleball and social time.

Ratcliff Appointed to AAFP Nominating Committee

Keith Ratcliff, MD, was recently appointed to the AAFP Nominating Committee, At Large Member, for a 3-year term. Reid Blackwelder, MD, Chair of the Nominating Committee stated that, “A number of variables were part of this decision-making process, which all involved trying to ensure that this diverse group will best reflect our membership and depth and breadth of perspectives.” Dr. Ratcliff easily checks the boxes for this expertise.

The MAFP letter of support for Dr. Ratcliff’s nomination pointed out that Dr. Ratcliff’s knowledge of and experience with the AAFP and MAFP will bring a strong background to the Nominating Committee. Keith represented MAFP at the AAFP Congress of Delegates and has offered sage testimony and recommendations on the issues brought before this governing body. His experience as a practicing family physician in a solo practice, direct primary care practice, telemedicine, urgent care, emergency department, and as an employed physician makes him uniquely prepared to review the qualifications for future AAFP board members. His engagement with AAFP, MAFP, and other medical societies has introduced him to the expectations of a strong leader. His experience makes him keenly aware of the qualifications needed to serve on the AAFP board and address the priority issues facing family physicians and medicine.

Congratulations Dr. Ratcliff!

Mohammad Abbas, DO

Nicholas Brendle, DO N. Stephen Doyel, DO

Danial Hussain, DO

Kade Kinney, DO

Heshaam Latiﬁ, DO

Noor Yassine, DO

Anthony Park, DO

Teresa Ngo, DO

Danial Hussain, DO

Kade Kinney, DO

Heshaam Latiﬁ, DO

Stephen Doyel, DO

Danial Hussain, DO

Kade Kinney, DO

Heshaam Latiﬁ, DO

Noor Yassine, DO

Anthony Park, DO

Teresa Ngo, DO

Capital Region Medical Center 2024-2025 Family

Medicine Residents

Kimberly Stroud, D.O.

Michael Dodson, D.O. Andrew Doppelt, M.D.

-2

-3

Daniel Hulse, D.O.

Aniqa Rahman, M.D. Chief Resident

Ishvara Om, D.O.

PGY-1

Kamil Adamczewski, D.O.

Zoya Gill, M.D. Aaron Laughlin, D.O. Ryan McLachlan, D.O.

Family Medicine Residency

Third - Year Resident Physicians

Second - Year Resident Physicians

First - Year Resident Physicians

Sharyl Alendry, DO Alexis Bean, MD, Chief Resident Elizabeth Born, DO

Mallory Howard, DO

Melanie Kim, DO

Katelynn Main, DO Kevin Martin, DO

Colby Smith, DO Michelle Smith, MD, Chief Resident Colton Webber, DO

Jonathan Bingham, DO Hannah Boehler, DO

Denim Bryson, DO

Erica Casey, MD

Shelbi Davis, MD

Mason Farris, DO

Melissa Medley, DO

Haley Olsen, DO

Cerena Stinogel, DO

Tessa Tolen, DO

Maggie Baker, MD Austin Bell, MD

Kelsey Ellis, DO

Quincey Fort, DO Brady Garmon, DO

Noah Holmes, DO

Michael Lay, MD

Rebekah Miller, DO

Claire Reagen, DO Ashton Skopec, MD

2024 2025

Terrence Kelly, DO PGY 3

Andrea Pelate, MD PGY 3

Omar Rehman, DO PGY 3

Don “Michael” Kulasekera, DO PGY 3

Ehab Abdelaziz, MD PGY2

Brandyce Elia, MD PGY2

Upagya Kompalli, MD PGY2

Cuong “Yoshi” Le, DO PGY2

Robert Morris, DO PGY2

Christopher Johnson, DO “Gil” PGY1

Timothy Mayes, DO PGY1

Ashley McCleary, DO PGY1

Tammy Wicke, DO PGY1

Kayla Woodward, DO PGY1

Chief Resident Chief Resident

Mercy Family Medicine

2024-2025 Resident Roster

First-Year Resident Physicians | Class of 2027

Second-Year Resident Physicians | Class of 2026

Third-Year Resident Physicians | Class of 2025

Noah Brown, MD Advisor: HOEKZEMA

Emma Gloe, MD Advisor: COLE

Charles Hill, DO Advisor: DANIS

Mason Lee, DO Advisor: WHITE

James Michaud, DO Advisor: VERRY

Emily Ratchford, MD Advisor: WILFLING

Kelly Dougherty, MD Advisor: WILFLING

Ashlyn Edwards, DO Advisor: WHITE

Rebecca Jadwisiak, DO Advisor: HOEKZEMA

Emily Shank, DO Advisor: VERNA

Sarah Spearman, DO Advisor: PHRUTTITUM

Jordan Wills, MD Advisor: VERRY

Oresta Agastra, MD Advisor: HOEKZEMA

Bezawit Getahun, MD Advisor: BRENNAN

Erica Haste, DO Advisor: WHITE

Jacob Honey, MD Advisor: PHRUTTITUM

Saydee Nymeyer, MD Advisor: WILFLING

Justin Pelkey, DO Advisor: VERNA

James Thomas, MD Advisor: KAEFRING

Ashly Wattles, DO Advisor: MADDOX

Family Medicine Residency Program

SSM Health St. Mary’s Resident Physicians 2024-2025

Belaniesh Nigeda, D.O. PGY-1

Maura Walsh, M.D. PGY-1

Matthew Schneider, D.O, PGY-3

Manoja Uppugundri, D.O. PGY-3

Jonathan Charlu, M.D. PGY-3

Taylor Flowerday, M.D. PGY-3

Dakarai Moton, D.O. PGY-3

Adaoma Ngari, M.D. PGY-3

Robert Besancenez, M.D.PGY-2

Ishak Hossain, M.D. PGY-2

Lexi Kremer-Callahan, M.D. PGY-2

PGY 2

Gretchen Landgraf, D.O. PGY-2

Ashna Mahadev, M.D. PGY-2

Tyeler Rayburn, M.D. PGY-2

Thomas Cassimatis, M.D. PGY-1

Galen Hoft, D.O. PGY-1

Farhan Hussain, M.D. PGY-1

Joseph Mooney, M.D. PGY-1

FAMILY MEDICINE RESIDENTS

2024-2025

FAMILY MEDICINE RESIDENTS

Alex Holbrook, DO PGY-1

James Liu, DO PGY-1

Anna Livingstone. DO PGY-1

Colten Pluff, MD PGY-1

Kailyn Baalman, MD PGY-2

Nicholas Gutzmer, DO PGY-2

Kirstie Mabitad, DO PGY-2

Efren Shahabeddin, MD PGY-2

Alex Downey, DO PGY-3

Grant Paterson, DO PGY-3

Allison Politsch, DO PGY-3

Charles Shipley, DO PGY-3

Alex Holbrook, DO PGY-1

James Liu, DO PGY-1

Anna Livingstone. DO PGY-1

Colten Pluff, MD PGY-1

Kailyn Baalman, MD PGY-2

Nicholas Gutzmer, DO PGY-2

Kirstie Mabitad, DO PGY-2

Efren Shahabeddin, MD PGY-2

Alex Downey, DO PGY-3

Grant Paterson, DO PGY-3

Allison Politsch, DO PGY-3

Charles Shipley, DO PGY-3

DEPARTMENT

Third-Year Residents

Second-Year Residents

First-Year Residents

Bothwell Residents

Integrated Residents

LEE’S SUMMIT FAMILY MEDICINE RESIDENCY

Mariyam Sadikot, MD

Aliza Tan, DO

Christopher Miller, MD

Jasmine McAllister, MD

Natalie Powell, DO

Kaitlyn Long, DO Sahil Shah, MD

Shalin Patel, DO

Bre’on Long, MD

Karin Cherniak , DO

Andrew Kraft, MD

Max Gove, DO

Samuel Little, MD

Raymond Le, D O

Alissa Iseman Program Administrator

Nicolle Gunter, MD Inpatient Lead

CLASS OF 2026

Ryan Ansari, MD Ali Haider Arsiwala, MD

CLASS OF 2027

Sparshitha Adapa, MD Chen Bo Fang, MD

Kristian De Nagel , M D Core Faculty / Sports Medicine

Melissa Smith, MD Clinic Lead

Karen Foote, MD Associate Program Director

FACULTY / STAFF

Lawrence Gibbs, MD Program Director

BOTHWELL-UNIVERSITY OF MISSOURI

FAMILY MEDICINE RESIDENCY

RURAL

SECOND-YEAR RESIDENTS

THIRD-YEAR RESIDENTS

FIRST-YEAR RESIDENTS

Gabriel Dudley, DO

Brittany Pendergraft, MD

Levi Harris, DO

Jamie Spears, MD

ShiAnne Farris, DO

Logan Stiens, MD

References

Pediatric Mental Health Guide pages 6-7

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The Relationship Between Social Media, Mental Health, and Relationship Wellness: A Literature Review

pages 8-11

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Promoting Physician Well-being in Addiction Care: Three Essential Strategies

pages 12

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Systematic Review of Perinatal Suicidal Behaviors Risk Factors

pages 13-16

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60. Yu, H., Shen, Q., Bränn, E., Yang, Y., Oberg, A. S., Valdimarsdóttir, U. A., & Lu, D. (2024).

61. Perinatal depression and risk of suicidal behavior. JAMA Network Open, 7(1), e2350897. https://doi.org/10.1001/jamanetworkopen.2023.50897

32ND ANNUAL FALL CONFERENCE SCHEDULE

THURSDAY, NOVEMBER 7, 2024

32ND ANNUAL FALL CONFERENCE

6:00-8:00 pm OMT For All Physicians: Interactive Osteopathic Manipulation Therapy Introduction for MDs and Refresher for DOs

SATURDAY, NOVEMBER 9, 2024

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

THURSDAY, NOVEMBER 7, 2024

George Chou, DO

Jayme Decker, DO, MS

FRIDAY, NOVEMBER 8, 2024

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

6:00-8:00 pm OMT For All Physicians: Interactive Osteopathic Manipulation Therapy Introduction for MDs and Refresher for DOs

8:00-9:00 am State of Missouri Medicine

Heidi Miller, MD

George Chou, DO

7:00-8:00 am Sunrise Walk to Nelson-Atkins Museum of Art Hosted by Kansas City Academy of Family Physicians

8:00-9:00 am Perinatal Cardiovascular Health: Fourth Trimester Risks, Evaluation, and Care

Jayme Decker, DO, MS

MO Department of Health and Senior Services Chief Medical Officer

FRIDAY, NOVEMBER 8, 2024

9:00-10:00 am Colorectal Cancer Screening: Guidelines, Options, and Patient Care

Brad Garstang, MD

10:00-10:30 am Break with Exhibitors

Natalie Long, MD

9:00-10:00 am Moving the Needle in Older Adults: A Physician Townhall to Enhance Vaccine Uptake

Keisha Harvey-Mansfield, MD, FAAFP, DABFM, DABOM, DABLM

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

10:30-11:30 am Direct Primary Care: What, Why, How

10:00-10:30 am Break with Exhibitors and Raffle Drawings Must be present to win

8:00-9:00 am State of Missouri Medicine

Teresa Lovins, MD, FAAFP

11:30-12:00 pm MAFP Annual Meeting

Heidi Miller, MD

12:00-1:00 pm Missouri Legislative Initiatives and AAFP Update Luncheon

10:30-11:30 am Testosterone Tales: How to Spot It, Prescribe It, and Keep It in Check for Life!

Todd Shaffer, MD, MBA, FAAFP

MO Department of Health and Senior Services Chief Medical Officer

Sarah Cole, DO, FAAFP, MAFP Advocacy Commission Co-Chair

Teresa Lovins, MD, FAAFP, AAFP Board Member

1:00-2:00 pm Elevating Patient Care: Early Detection and Evidence-Based Pharmacotherapy for Postpartum Depression in Primary Care

11:30-12:30 pm ABFM Update: The Now and Future of ABFM Board Certification

Gary LeRoy, MD, FAAFP

12:30-1:30 pm Pediatric ADHD Diagnosis and Treatment: Behavioral and Pharmacotherapy Strategies to Improve Patient Outcomes

9:00-10:00 am Colorectal Cancer Screening: Guidelines, Options, and Patient Care

Brad Garstang, MD

Sarah Nagle-Yang, MD

2:00-3:00 pm Dermatology Essentials for Family Physicians: A Comprehensive Review

Gaurav Kulkarni, MD

1:30-2:30 pm Breathing Easy: Conquering Obstructive Sleep Apnea for Better Health

10:00-10:30 am Break with Exhibitors

Charlie Rasmussen, DO, FAAFP

3:00-3:30 pm Break with Exhibitors

Suzanne Bertisch, MD, MPH

Lindsay Liles, MD, DABOM

2:30-3:30 pm What Primary Care Clinicians Need to Know About MASLD and MASH

10:30-11:30 am Direct Primary Care: What, Why, How

Teresa Lovins, MD, FAAFP

3:30-4:30 pm Practical Tips for Hepatitis C Management

Kento Sonoda, MD, FAAFP, AAHIVS, FASAM

Eugene E. Wright, Jr. MD

COMMISSION AND BOARD MEETINGS

4:00-5:30 pm Advocacy Commission - Pavilion I Member Services Commission - Pavilion II Education Commission - Pavilion III MAFP Board Meeting - Pavilion I

Missouri Legislative Initiatives and AAFP

Sarah Cole, DO, FAAFP, MAFP Advocacy

All CME sessions are in Salon I. The exhibit hall in Salon II and III is open during times listed on the schedule. Application for CME credit has been filed with the American Academy of Family Physicians. Determination of credit is pending. Schedule is subject to change.

Teresa Lovins, MD, FAAFP, AAFP Board Member

SATURDAY, 7:00-8:00 am 7:00-8:00 am 8:00-9:00 am 9:00-10:00 am 10:00-10:30 10:30-11:30 am 11:30-12:30 pm 12:30-1:30 pm

Missouri Family Physician: Mental Health Insights

FP

Courtney De Souza, M.D.

Recruiting experts like you.

Recruiting experts like you.

CONSTRUCTION IN PROGRESS

CONSTRUCTION IN PROGRESS

FAMILY PRACTICE OPPORTUNITIES

FP

CONTENTS

Reflections on My Leadership Journey Through Family Medicine

Pediatric Mental Health Guide

ANXIETY

MOOD DISORDERS

ATTENTION DISORDERS

TIPS FOR MENTAL HEALTH VISITS

DO

DON’T

TOOL KIT

The Relationship Between Social Media, Mental Health, Relationship Wellness: A Literature Review

METHODOLOGY

FINDINGS

PERSONAL DISPOSITIONS

CONTENT ENGAGED

TIME SPENT

DISCUSSION

RECOMMENDATIONS

CONCLUSION

Promoting Physician Well-being in Addiction Care: Three Essential Strategies

Set appropriate expectations

Maintain boundaries

Peer debriefing

Systematic Review of Perinatal Suicidal Behaviors Risk Factors

Systematic Review of Perinatal Suicidal Behaviors Risk Factors

Methods

Searches, Data Extraction, and Planned Analysis

Figure 1

Results

Behavioral Health

General Mental Health

Mental Health Diagnosis, Trauma History, and Suicidality

Assessment and Continuity of Care

Chronic Health

Delivery and Pregnancy Outcomes

Psychosocial risks

Historically Marginalized Populations

Intimate Partnerships

Discussion

Behavioral Health

Chronic Health Conditions

Pregnancy, Delivery, and Infant Outcomes

Psychosocial Factors

Limitations

Points for Practice

Conclusion

ADVOCACY DAY FEBRUARY

2024 Summer Externs: Stories and Reflections from the Field

Ashvika Baskaran, OMS1

Isabella De La Torre, MS1

Meghana Mettu, OMS1

Transition Conference Prepares Students and Residents for Success

2024 Family Medicine Mixers

June 21, 2024

BigShots Golf, Springfield Sponsored by CoxHealth

June 21, 2024

BigShots Golf, Springfield Sponsored by CoxHealth

July 31, 2024 Kansas City Zoo

August

St. Louis Zoo

Sponsored by SSM Health

September

Physician Wellbeing Remains Critically

Low; New Survey

Unveils

Impact of Healthcare Consolidation

Urgent Need for Solutions to Improve State of Current and Future Physician Wellbeing

Missouri’s Residents and Students Truly are Leaders in the Nation

MEMBERS IN THE NEWS

Laura Morris, MD: Mizzou’s Vaccine Expert and Mentor in Family Medicine

Dougherty Recognized as National Leader