missouri family physician magazine jan-mar 2013

MISSOURIOfficial Publication of the Missouri Academy of Family Physicians

Jan-Mar 2013Volume 32, Issue 1

Family Physician2012 AAFP Congress of Delegatespg. 18

Resident Grand Rounds Nicholas D'Angelo, MD pg. 10

Academy In Action

Pharmacy Protocol Caution pg. 6

CDC Imlements New Changes pg. 7

Photo provided by LBJ Images

Missouri Family Physician January - March 2013 3

Inside this issue17 2013 Advocacy Day Registration18 AAFP Congress of Delegates Report19 Thank you 2012 AFC Sponsors & Exhibitors19 MAFP Needs Assessment Survey19 Seeking Physician Volunteer

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2 Cox Health4 National Dairy Council9 Evidence-Based Practice/FPIN12 2013 Annual Fall Conference15 Core Content Review17 United Allergy Services19 HEALTHeCAREERS20 Missouri Professionals Mutual

4 The ABC's of Medicine Kate Lichtenberg, DO, MPH, FAAFP5 Time Better Served George Harris, MD, FAAFP6 Pharmacy Protocol Caution Arthur Freeland, MD, FAAFP7 CDC Implements New Changes8 Help Desk Answers Resident Case Studies10 Resident Grand Rounds Nicholas D'Angelo, MD12 New SLAFP President Installed Sarah Cole, DO, FAAFP14 Why Do I Teach Tar Wars? Susan Lentz, RN, BSN 15 Nominate 2013 Family Physician of the Year Deadline - March 1, 201316 Members in the News

MAFPContents

Executive CommissionBoard Chair - Todd Shaffer, MD, MBA (Lee’s Summit) President - Kate Lichtenberg, DO, MPH (Kirkwood)President-elect - Bill Fish, MD (Liberty)Vice President - Daniel Purdom, MD (Independence)Secretary/Treasurer - Tracy Godfrey, MD (Joplin)

Board of DirectorsDistrict 1 Director: Dana Granberg, MD Alternate: Jennifer Moretina, MDDistrict 2 Director: Lisa Mayes, DO Alternate: VacantDistrict 3 Director: Jeff Suzewits, DO Director: F. David Schneider, MD Alternate: Caroline Rudnick, MDDistrict 4 Director: Kelly Bain, MD Alternate: Jennifer Stearnes-Rosas, MD District 5 Director: Peter Koopman, MD Director: Katherine Friedebach, MD Alternate: James Stevermer, MD, MSPHDistrict 6 Director: Jamie Ulbrich, MD Alternate: VacantDistrict 7 Director: Kathleen Eubanks-Meng, DO Director: George Harris, MD, MS Alternate: VacantDistrict 8 Director: Mark Woods, MD Director: John Paulson, DO, PhD Alternate: VacantDistrict 9 Director: Charlie Rasmussen, DO Alternate: VacantDistrict 10 Director: Mark Schabbing, MD Alternate: Steven Douglas, MD

Resident DirectorsSuzan "Annie" Lewis, DO Imani Anwisye, MD (Alternate) Student DirectorsDavid Kramer Amanda Williams (Alternate) AAFP DelegatesBruce Preston, MD Larry Rues, MD Darryl Nelson, MD (Alternate)

MAFP StaffExecutive Director - Jennifer BauerEducation & Finance Director - Nancy GriffinManaging Editor/Member Services - Laurie Bernskoetter

Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p (573) 635-0830 f (573) 635-0148 www.mo-afp.org [email protected]

Mark yourCalendar

3rd Annual Advocacy Day State Capitol, Jefferson City, MO February 26, 2013

AAFP ALF/NCSC Kansas City, MO April 25-27, 2013

65thAnnualScientificAssembly The Lodge of Four Seasons, Lake Ozark, MO June 7-9, 2013

21st Annual Fall Conference & SAM Working Group Big Cedar Lodge, Ridgedale, MO November 8-10, 2013

Register now! See pg.17

Do you needCME?

Mark your calendar!

Join us for the 65th Annual Scientific Assembly

to be held atThe Lodge of Four Seasons

Lake Ozark, MO

June 7- 9, 2013

Look for updates coming soon!

www.mo-afp.orgwww.4seasonsresort.com

SGR, PCMH, HIPPA, ACOs, ACA . . . the acronyms keep coming. Medicine is confusing

enough with day-to-day patient care, but keeping up with ever changing business of medicine can be even more daunting. There has been a lot of talk about the dying breed of solo and small-group practices. While in Philadelphia for the Congress of Delegates, I was struck by the number of small practices that were struggling. I spoke with more than a couple of physicians who had to close their practices down and often they were the only physicians in the area.

There was a lot of talk about

Patient Centered Medical Homes and the hardship for smaller practices to achieve that goal. Pilot projects are popping up with different insurance companies. If you are not lucky enough to be a part of a pilot, the struggle continues. The good news is that more insurance companies see the benefit of incorporating PCMH tents and may start rewarding more practices for doing this.

If you are trying to achieve PCMH, you know the costs involved. Just picking which accrediting body to use can be confusing. Do your homework ahead of time and find the program that works for you. If there are insurance companies in your

area that are paying additional for PCMH certification from a specific organization, try to go with that one.

Not sure you are even ready to begin yet or where to start? Try the PCMH preparation checklist that can be found on AAFP’s website. Family physicians are in a unique position right now with all of the changes that are occurring in medicine. We will emerge as leaders of the health care teams and our patients will reap benefits from that.

As always, if you have thoughts, concerns, or ideas for your Academy, please contact our office in Jefferson City. We want to hear from you to make our Academy the best it can be

The ABC's of MedicineKate Lichtenberg, DO, MPH, FAAFP2012-2013 MAFP President

MAFP President's Perspective

4 Missouri Family Physician January - March 2013


The elections are now complete and the end of year legislative decisions concerning health care

including the funding for the payment of physician’s care of patients, especially Medicare, is upon us.

It is disappointing that each year physicians and their medical associations have to take the time and spend the money for special trips to Washington, DC, and to write additional letters to our senators and congressman in order to defend and prevent the decrease in payments for physicians’ services. There are no other professions or employers who require one to defend for the payment of their services or products rendered.

Physicians understand having to make and follow a budget; evaluate your expenditures the past year and project expenditures for the coming year. Individuals also know how to follow a budget; a budget also has to be based on the projected income. Unfortunately, Congress has not realized how to create and follow a balanced budget.

In 1997, Congress passed the Balanced Budget Act in an effort to reduce budget deficits. Part of this law outlined a “sustainable growth rate” (SGR) for Medicare payments to doctors under Medicare Part B. The SGR replaced the Medicare Volume Performance Standard (MVPS), which was the previous method used in an attempt to control costs. The SGR has attempted to control the growth rate for Medicare Part B expenditures by ensuring that the yearly increase in the expense per Medicare beneficiary did not exceed the growth in GDP. Unfortunately, SGR has not done a

good job in accomplishing this goal. However, it has prevented

adequate physician payment for services. Physicians are receiving payments at basically the same rate as in 2001. I do not know of any other profession or employment where there is this significant lack of pay increases.

Physicians are aware that Medicare Part B’s expenditures come from a fee schedule containing over 7,000 services that they bill Medicare. Every year, the CMS sends a report to the Medicare payment Advisory Commission, which advises the U.S. Congress on the previous year's total expenditures and the target expenditures. The report includes a conversion factor that will change the payments for physician services for the next year in order to match the target SGR. If the expenditures for the previous year exceeded the target expenditures, then the conversion factor decreases payments for the next year. If the expenditures were less than expected, the conversion factor increases the payments to physicians for the next year. Annually, on March 1, the physician fee schedule is updated accordingly. After 15 years of following this approach, it should seem to all involved that this law lacks effect and benefit to all concerned.

In 2009, the health expenditure per capita in the United States was $7960 (in 2004, it was $6096) representing 17.6% of gross domestic product. There are many components to health care expenditures. Somehow, the physician payment for services continually is the segment that is identified as effecting the costs of total health care expenditures. These expenditures include all of the areas

of improving health – medical care, prevention, promotion, rehabilitation, community health services, health administration and regulation, medical education and training, research and development. In order to have a significant impact on the U.S. health care expenditures, a cost-benefit analysis of each component needs to be performed making each responsible and accountable for the monies received. There are several components listed that need to be adjusted in their spending. If health care expenditures are to be addressed by this Congress, then all aspects need to be reviewed and considered targets for reduction including Medicaid.

In an era when there are not enough primary care physicians, I find the annual combat of dealing with the SGR and adequate physician payment for services disappointing and disheartening for those students considering medicine as a profession. Not only does the doubtfulness of payment for services seem concerning, but the continual increase in medical school education and training become very daunting. To graduate from medical school with loans exceeding $150,000-$200,000 or more, discourages well-qualified students from considering medicine as a career but also diminishes significantly the number of students who will be choosing a primary care specialty in family medicine, general pediatrics or internal medicine, to practice during their career.

The Affordable Care Act, the patient-centered medical home nor the accountable care organizations can

Time Better ServedGeorge Harris, MD, FAAFP

2012-2013 MAFP Member Services Commission Co-Chair

MAFPTime Better Served

continued on page 7


In 2007, a bill was brought forward in your Missouri Legislature to enable pharmacists to provide

more immunizations than the simple inf luenza vaccine that they had been administering for several years. The new immunizations that they asked for included pneumonia, meningitis, and herpes zoster vaccines for adults. Why these vaccines you might ask? Is the burden of disease greater for these than other adult vaccines? Hepatitis A comes to mind. Perhaps, but what at least two of them have in common is a hefty price with a potentially decent profit margin.

Your Advocacy Commission did not think it outlandish for pharmacists to administer these vaccines (or most others, for that matter). What we did feel was that the patient’s physician had a better handle on who actually needed them, as well as situations where, even in the absence of an absolute contraindication, a live virus vaccine might raise risk for the patient or their close contacts. With this in mind, the MAFP and the MSMA supported giving the pharmacists statutory authority to administer those vaccines “by written protocol authorized by a physician for a specific patient.” (emphasis mine)

There is another section which had been present previously that allowed for inf luenza vaccine “by written protocol authorized by a physician,” along with a separate clause stating that the inf luenza protocols would be jointly promulgated by the Board of Pharmacy and the Board of Healing Arts.

At the end of the session in 2009, four words were inserted in the section

about the inf luenza vaccine protocol. Added were “pneumonia, shingles, and meningitis” vaccines. Since these were only added to the protocol section and not the section requiring input from the Board of Healing Arts, input from you as a patient’s physician, from MAFP as a professional organization, and from the Board of Healing Arts are not a part of the decision whether or not your patient receives these vaccines.

I owe you an apology. We missed this when it was stealthily inserted as part of a large omnibus bill late in the session (probably because it echoed language in another line of the bill). We again missed it when the enabling rules were proposed (though the way these are written they could apply to any vaccine including simple inf luenza). It was only discovered (as intended, I’m sure) when Walgreens started advertising ‘Zostavax on demand’ last summer.

The rules promulgated to cover this are in the Missouri Code of State Regulations (CSR 2220-6.050). It does reference CDC guidelines and manufacturer’s guidelines (which include indications and absolute contraindications) but does not address rare or contact risks. And, tellingly, subsection 3 reads:

(3) The authorizing physician is responsible for the oversight of, and accepts responsibility for, the vaccines administered by the pharmacist.

And Subsection (5) (A) 6.:6. A provision to create a prescription for each administration under the authorizing physician’s name.Now, you may have received

an invitation to review and sign a protocol for the administration of these vaccines - each pharmacy needs a physician who practices within 50 road miles of their facility to do so. You might have even signed one. Please note that as the rules state, if you sign the protocol, you become the ordering physician, and bear responsibility for the administration of vaccines that occur at that pharmacy. This amounts to calling in a variety of prescription injections for an unknown number of patients - sight unseen. In solicitations I received, the going rate for signing that protocol was $200.

So, what does this mean to you and me?

First, this is more evidence that clinical issues very important to patients, to the profession of medicine and to pharmaceutical profits are more and more going to be addressed in the political arena. Increasingly, this may happen by backdoor routes that are not exposed to public debate. You, individually, and the MAFP as an organization, need to be more knowledgeable about, and integral to, the legislative process. This requires that we have many more members who know their legislators, and who are active on our Advocacy Commission.

Secondly, the advocacy commission really needs to be able to divide up and review “with a fine-toothed comb” actual bill language, as well as regulation language for issues that affect us and our patients. We had a brief window where we could have made a difference when this amendment was inserted, and a longer window when the regulations were proposed and we just didn’t catch it. Again, more

MAFP Pharmacy Protocol Caution

Pharmacy Protocol Caution!Arthur Freeland, MD, FAAFP 2012-2013 MAFP Advocacy Commission Co-Chair

>>

MAFPImmunizations Update from CDC

provide all of the changes needed to move forward with a more efficient, cost-effective, and high quality-type of medical care. It will also require more patient accountability and responsibility, more emphasis on prevention, more financial contributions from large health care delivery systems and insurers, appropriate payment for cognitive, procedural and technical services and evaluating the cost-to-benefit ratio for every component of the delivery of health care.

Time would be better spent on addressing these areas than an annual debate on the SGR. It is time for effective not political health care reform and the permanent reform to the SGR so that physician payment rates are not subject to these annual cuts.

members active in advocacy and being more organized would help.

Lastly, if you are considering signing an immunization protocol, you need to decide if you wish to accept responsibility for the adverse events, complications, side effects, and any untoward outcomes that might occur in hundreds of patients with which you have no relationship whatsoever.

How brave are you?

1. The actual law is Section 338.010, RSMo., found at: http://www.moga.mo.gov/statutes/C300-399/3380000010.HTM

2. The regulations - CSR 2220-6.050, can be found at: http://www.sos.mo.gov/adrules/csr/current/20csr/20c2220-6.pdf

The Centers for Disease Control and Prevention (CDC) implemented changes to Section 317 policy. Starting October 1, 2012, Section 317 vaccine may not be used for routine vaccination of any fully insured individual. The CDC defines fully insured as:

Anyone with insurance that covers the cost of vaccine, even if the insurance includes a high deductible or co-pay, or if a claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier because the plan's deductible had not been met.

In order to assure that 317 vaccine remains available for those who truly have no other option, it is important that all fully insured children are vaccinated with vaccines purchased through their insurance. The Vaccines for Children (VFC) program will continue to serve eligible children and adolescents.

This 317 policy change, which specifies that Section 317 vaccines should not be used for routine vaccination of full-insured children, adolescents and adults, affects both the public and private sectors.

Private physicians who have been referring their patients to public health clinincs for routine vaccination will need to consider how to meet the preventive care needs of their fully insured patients because the health department will no longer be able to vaccinate fully insured individuals, except in a few limited cases, such as an infant born to a Hepatitis B infected mother or during public health response activities. Similarly, insurance providers will need to ensure adequate in-network providers to vaccine all of the individuals covered under their plans.

For more information regarding this policy change, contact your local health department or the Missouri Department of Health & Senior Services, Bureau of Immunization Assessment and Assurance at 800-219-3224. You may also visit: www.health.mo.gov/immunizations, a new web site tailored to health care professionals, parents, schools, child care facilities, and other consumers. This new site provides details on the Vaccines for Children program including eligibility, forms, communication, a locator tool to connect parents with program providers and Missouri's immunization registry, ShowMeVax.

CDC Implements New Changes

Routine Vaccination Update

click on the "VFC Provider

Communication" tab in blue at the

bottom of the webpage.

Time Better Served continued from page 5

Pharmacy Protocol Caution


>>


About HDAs - Resident authors work directly with a physician faculty mentor as “author teams”. Residencies meet RRC requirements, and many programs have developed their

faculty into local evidence-based medicine experts!

October 2012 EBP

MAFP Help Desk Answers

A 2003 RCT assigned women age ≥18 with ASCUS (n=3,488) to immediate colposcopy, high-risk HPV screening, or repeat cytology semiannually.1 All women had Pap smears at enrollment and semiannually for 2 years, then underwent colposcopy at exit. Patients also had colposcopy if they were HPV-positive at any time during the study. The study endpoint was 2-year cumulative diagnosis of CIN3. In women with ASCUS, HPV screening detected 92% (95% CI, 89-95) of individuals ultimately detected to have CIN3 while referring only 53% (95% CI, 52–55) of the ASCUS group to colposcopy. The authors concluded that HPV screening in ASCUS was as effective as immediate colposcopy.

A similar RCT assigned women with LSIL (n=1,572) to groups receiving surveillance protocols similar to those in the prior study.2 Study design and endpoints were the same as above. In women with LSIL, HPV screening detected 95% (95% CI, 92–98) of individuals ultimately detected to have CIN3; however a high percentage, 84% (95% CI, 82–86), were referred to colposcopy for positive HPV. Thus, the HPV arm of the LSIL study closed early. The authors concluded that HPV screening in LSIL was not beneficial and recommended immediate colposcopy.

A 2009 prospective case-control study performed Pap smear and HPV-DNA analysis in 197 women ages 21–60 with known ASCUS to determine if HPV testing assisted in the detection of CIN2 or CIN3.3 Colposcopy was performed if patients were (1) ASCUS+/HPV+, (2) ASCUS–/HPV+, or (3) ASCUS+/HPV– based on repeat Pap at study entrance. All women were re-examined after 3 years. CIN2 or CIN3 was detected in 41% of cytology+/HPV+, in 20% of cytology–/HPV+ women, and in none of the cytology+/HPV– groups. The addition of HPV testing in secondary screening of ASCUS-positive women increases the detection of CIN2 or CIN3 by 33% (P=.01) when compared with repeat cytology.

The 2006 evidence-based guidelines for the management of women with abnormal cervical cancer screening tests are based on a systematic review of the literature available at the time.4 The guidelines recommend HPV testing as a follow-up for ASCUS in patients aged >20 (TABLE). The guidelines advised against HPV testing as a sole screening method. In 2012, the USPSTF stated that, for women aged 30–65 years who wanted to lengthen their

Evidence-Based Practice / Vol. 15, No. 10 5

In patients with cytologic abnormalities on Pap smear, what are the indications for HPV DNA testing?

Evidence-Based AnswerScreening for high-risk human papilloma virus (HPV) can be helpful in addition to cytology in women age >30, for triage in women age >20 with atypical squamous cells of undetermined significance (ASCUS), and for follow-up of a negative colposcopy in women with atypical squamous cells–cannot rule out high grade (ASC-H) (SOR: A, RCTs and evidence-based guidelines). HPV testing in ASCUS increases the detection of cervical intraepithelial neoplasia (CIN) 2 and 3 (SOR: B, prospective case-control study).

A 2003 RCT assigned women age ≥18 with ASCUS (n=3,488) to immediate colposcopy, high-risk HPV screening, or repeat cytology semiannually.1 All women had Pap smears at enrollment and semiannually for 2 years, then underwent colposcopy at exit. Patients also had colposcopy if they were HPV-positive at any time during the study. The study endpoint was 2-year cumulative diagnosis of CIN3. In women with ASCUS, HPV screening detected 92% (95% CI, 89-95) of individuals ultimately detected to have CIN3 while referring only 53% (95% CI, 52–55) of the ASCUS group to colposcopy. The authors concluded that HPV screening in ASCUS was as effective as immediate colposcopy. A similar RCT assigned women with LSIL

(n=1,572) to groups receiving surveillance protocols similar to those in the prior study.2 Study design and endpoints were the same as above. In women with LSIL, HPV screening detected 95% (95% CI, 92–98) of individuals ultimately detected to have CIN3; however a high percentage, 84% (95% CI, 82–86), were referred to colposcopy for positive HPV. Thus, the HPV arm of the LSIL study closed early. The authors concluded that HPV screening in LSIL was not beneficial and recommended immediate colposcopy. A 2009 prospective case-control study performed Pap smear and HPV-DNA analysis in 197 women ages 21–60 with known ASCUS to determine if HPV testing assisted in the detection of CIN2 or CIN3.3 Colposcopy was performed if patients were (1) ASCUS+/HPV+, (2) ASCUS–/HPV+, or (3) ASCUS+/HPV– based on repeat Pap at study entrance. All women were re-examined after 3 years. CIN2 or CIN3 was detected in 41% of cytology+/HPV+, in 20% of cytology–/HPV+ women, and in none of the cytology+/HPV– groups. The addition of HPV testing in secondary screening of ASCUS-positive women increases the detection of CIN2 or CIN3 by 33% (P=.01) when compared with repeat cytology. The 2006 evidence-based guidelines for the management of women with abnormal cervical cancer screening tests are based on a systematic review of the literature available at the time.4 The guidelines recommend HPV testing as a follow-up for ASCUS in patients aged >20 (TABLE). The guidelines advised

Indications for HPV screening based on age and Pap smear findings4

Patient group Screening recommendation

<20 years HPV screening is inappropriate regardless of cytologic findings (EII)

TABLE

>20 years with cytologic abnormalities ASCUS: ASC-H & LSIL: HSIL:

recommended (AI) inappropriate (EII) inappropriate (EII)

colposcopy (AII) colposcopy (AII) colposcopy (BII)

repeat pap at 6 and 12 months or repeat HPV at 12 months (CIII)

ASC-H=atypical squamous cells–cannot rule out high grade; ASCUS=atypical squamous cells of undetermined significance; HPV=human papilloma virus; HSIL=high-grade squamous intraepithelial lesion; LSIL=low-grade squamous intraepithelial lesion.AI: Good evidence of clinical benefit, based on at least 1 RCT.AII: Good evidence of clinical benefit, based on 1 clinical trial, cohort study, or case-control trial.BII: Limited clinical benefit, based on 1 clinical trial, cohort study, or case-control trial.

EII: Good evidence for adverse outcome, based on 1 clinical trial, cohort study, or case-control trial.

Evidence-Based AnswerScreening for high-risk human papilloma virus (HPV) can be helpful in addition to cytology in women age >30, for triage in women age >20 with atypical squamous cells of undetermined significance (ASCUS), and for followup of a negative colposcopy in women with atypical squamous cells–cannot rule out high grade (ASC-H) (SOR: A, RCTs and evidence-based guidelines). HPV testing in ASCUS increases the detection of cervical intraepithelial neoplasia (CIN) 2 and 3 (SOR: B, prospective case-control study).

In patients with cytologic abnormalities on Pap smear, what are the indications for HPV DNA testing?


A systematic review of 19 RCTs (N=2,256) evaluated the effect of inhaled epinephrine, nonepinephrine bronchodilators, glucocorticoids, or placebo in children <2 years of age with viral bronchiolitis.1 Outcomes included day 1 and day 7 admissions and LOS. Inpatients receiving inhaled epinephrine had a shorter LOS compared with albuterol (2 trials; N=292; mean difference –0.28 days; 95% CI, –0.46 to –0.09). Inhaled epinephrine reduced day 1 admissions for outpatients compared with placebo (5 trials; N=995; RR 0.67; 95% CI, 0.50–0.89; NNT=17), but not day 7 admissions. When restricted to 3 studies with low risk of bias comparing epinephrine with placebo, there was no difference in day 1 admissions (N=842; RR 0.77; 95% CI, 0.56–1.07). A single RCT (n=399) included in the review reported that inhaled epinephrine combined with systemic corticosteroids reduced day 7 admissions in outpatients compared with placebo (RR 0.65; 95% CI, 0.44–0.95).

A systematic review including 7 RCTs (N=581) evaluated the efficacy of nebulized 3% saline used in conjunction with bronchodilators (epinephrine, terbutaline, racemic epinephrine, salbutamol, albuterol) versus nebulized 0.9% saline in children <2 years of age with acute bronchiolitis.2 Nebulized 3% saline plus bronchodilator had a shorter mean LOS compared with nebulized 0.9% saline (mean difference –1.2 days; 95% CI, –1.6 to –0.77) for

the first 3 treatment days.A systematic review of 17 RCTs (N=2,596) assessed short-term

systemic or inhaled glucocorticoids compared with inactive placebo or another intervention (ie, bronchodilators, other glucocorticoid) in children <2 years of age with acute bronchiolitis.3 Inhaled or Evidence-Based Practice / Vol. 15, No. 12 23 systemic steroids did not reduce admissions on day 1 or 7. LOS was unchanged for in-patients. Six trials showed no significant difference in harms, and results of adverse events were not pooled due to heterogeneity.

A systematic review involving 28 RCTs (N=1,912) analyzed the effectiveness of nonepinephrine bronchodilators compared with placebo for acute bronchiolitis in children <2 years of age.4 Bron-chodilators (including salbutamol, albuterol, ipratropium bromide, terbutaline, and adrenergic agents not including epinephrine) did not significantly reduce rates of hospitalization, improve oxygen saturation, or reduce LOS. Oxygenation and clinical score out-comes exhibited significant heterogeneity.

Brady Didion, MDFletcher Allen Health Care/University of Vermont

Burlington, VTLaura Morris, MD

University of MissouriColumbia, MO

1. Hartling L, et al. Cochrane Database Syst Rev. 2011; (6):CD003123. [LOE 1a]2. Zhang L, et al. Cochrane Database Syst Rev. 2008; (4):CD006458. [LOE 1a]3. Fernandes RM, et al. Cochrane Database Syst Rev. 2010; (10):CD004878.

[LOE 1a]4. Gadomski AM, Brower M. Cochrane Database Syst Rev. 2010;

(12):CD001266. [LOE 1a]

MAFPHelp Desk Answers

From the authors who bring you HelpDesk Answers comes a relevant, concise, and clinically useful journal to assist you in delivering the best care to your patients –all without the

bias of industry support.

Evidence-Based Practice is published monthly by the Family Physicians Inquiries Network.

12 issues and 48 PRA Category 1 CME CreditsTM $119 Missouri Family Physician Reader or $59 FPIN

Member

To subscribe, or view a sample issue, visit www.ebponline.net or call 573-256-2066.

What are the most effective therapies for bronchiolitis?Evidence-Based AnswerIn children younger than 2 years of age, inhaled racemic epinephrine may reduce early admissions, but admission rates are the same by 1 week after initial presentation. Inpatient treatment with nebulized 3% saline plus bronchodilators reduces length of stay (LOS) compared with nebulized saline alone. Inhaled or shortterm systemic glucocorticoids do not affect admissions or LOS. Likewise, standard bronchodilators alone do not influence admissions or LOS (SOR: A, systematic reviews of RCTs).

sampling interval, a combination of Pap cytology and HPV testing every 5 years was acceptable.5

Sandra Minchow-Proffitt, MDJessica Miller, MD

Mercy Family MedicineSt. Louis, MO

1. ALTS Group. Am J Obstet Gynecol. 2003; 188(6):1383 1392. [LOE 1b]2. ALTS Group. Am J Obstet Gynecol. 2003; 188(6):1393–1400. [LOE 1b]3. Silverloo I, et al. Acta Obstet Gynecol Scand. 2009; 88(9):1006–1010.

[LOE 2b]4. Wright TC Jr, et al. Am J Obstet Gynecol. 2007; 197(4):346–355. [LOE 1a]5. Moyer VA, on behalf of the USPSTF. Ann Intern Med. 2012; 156(12):880–

891. [LOE 1a]


MAFP Resident Grand Rounds

A 78 year old previously independent woman with a past medical history of depression, osteoarthritis, and restless leg syndrome presented late one evening to the emergency room with complaints of fever, chills, fatigue, weakness, decreased appetite, and slight headache progressively worsening for 2 days. Physical exam revealed no abnormalities, including a normal neurological and skin examination. Her temperature was 35.7C, P 88, RR 20 and O2 sat 95% on room air. WBC was 15.0 with 88% neutrophils and had mild hyponatremia. CXR was normal. EKG showed normal sinus rhythm. A urinalysis revealed 3+ LE, positive nitrite, trace blood, >100 WBC, 4+ bacteria and 3+ ketones. She was admitted with a complicated UTI. Ceftriaxone was started in the ER and changed to piperacillin and tazobactam on the floor. Her home medications (Alendronate, Mirtazapine, Quetiapine, Ropinirole, Tramadol, Venlafaxine) were continued.

The following morning, her temperature rose to 39.1C (102.4F). She was somnolent and confused with limited speech. Her exam revealed she was oriented only to person, had decreased mobility of left upper and lower extremities with right-side gaze preference. Concern for an acute stroke prompted a CT head which showed mild generalized atrophy without obvious focal abnormalities or hemorrhage. Neurology was consulted. Further history obtained from the daughter revealed the patient recently returned from a 4 week trip to Massachusetts including rural locales. Two of those weeks were spent in a woodland cottage where she spent time outdoors.

An MRI brain reported right mastoid air cell fluid, right maxillary sinus retention

cyst, and focal areas of increased intensity in the basal ganglia. The early involvement of the basal ganglia without evidence of hemorrhage distinguishes viral etiologies of encephalitis such as eastern equine encephalitis virus, St. Louis Encephalitis Virus, and West Nile virus, from the much more common herpes simplex (HSV) encephalitis (4). At this time, blood cultures revealed GPC in chains, pairs and clusters so vancomycin was added. The patient was moved to the ICU and a lumbar puncture was performed.

The inflammatory profile of the CSF further suggested a viral etiology. CSF samples were sent for common viral and bacterial cultures, HSV, West Nile Virus, Borrelia burgdorferi, EEEV, Tularemia, Rickettsia and Ehrlichia. ID was consulted. Doxycycline was added, Piperacillin/tazobactam discontinued, Ceftriaxone restarted, Vancomycin continued, and acyclovir initiated. An EEG was obtained and showed significant slowing (R > L), striking periodic waves over the right frontotemporal region with no evidence of epileptiform activity. These findings are consistent with encephalitis.

At this point, she did not respond or open her eyes to verbal or tactile stimuli, but she did respond to painful stimuli.

Supportive management was continued and over the following days the patient’s neurologic function began to improve. Eventually, she regained full consciousness and slowly began responding to questions and moving all four limbs.

The CSF and serum samples revealed a greater than 10-fold rise in IG-M antibody titre against EEEV which alone is sufficient for the diagnosis of EEE. PCR of CSF for EEE viral RNA later reinforced the diagnosis.

On 09/08/2011, she was able to follow one-step commands and occasionally two-step commands, but she was unable to follow any three-step commands. She was able to answer simple yes/no questions with 90% accuracy. Simple naming and repetition (repeating short phrases) were normal. She had persistent forgetfulness and confusion.

Re-evaluation on 04/13/2012 showed improvement. However, she continued to have moderate to severe dementia notably affecting anterograde learning, memory and aspects of executive functioning. Milder deficiencies in aspects of language, orientation, aspects of visual processing, and elements of language were also noted.

EEEV- Discussion When a patient presents with an acute

First Reported Case of Eastern Equine Encephalitis Virus in MissouriNicholas D'Angelo, MD, Completed Mercy FM Residency Sandra Minchow-Proffitt, MD, Mercy FMR FacultyJames Deckert, MD, Mercy FMR Faculty

Component Value Normal RangeColor/appearance Clear, colorless Clear, colorlessGlucose 56 mg/100 mL 50 - 80 mg/100 mLProtein 107 mg/100 mL (H) 15 - 60 mg/100 mLWBC 190/μL (H) 0-10/μLRBC 18/μL (H) 0/μLNeutrophils 3% 0-6%Lymphocytes 67% 40-80%Monocytes/Histiocytes 30% 15-45%

Nicholas D'Angelo, MD


flu-like prodrome, with headache, high fever, and altered level of consciousness, encephalitis should be suspected. New onset seizures, focal neurologic signs, irritability, restlessness, drowsiness, anorexia, vomiting, diarrhea, and cyanosis are important indicators as well. Priorities are to ensure airway protection, assess and document level of consciousness using a quantitative scale such as the Glascow Coma Scale. A full neurologic exam should be performed, including testing for meningism and observing for subtle motor seizures. It is important to document mini-mental exam scores and any odd behavior. A comprehensive skin exam is important in finding any rashes, bites, injection sites, exanthems, or indicators of immunocompromise such as Kaposi’s sarcoma or oral candidiasis (7).

History provides vital information, and if the patient is confused, additional information should be obtained from others. Questions should include travel history including activities and environment such as hiking or swimming, recent rashes, infections among close contacts, vaccination history, and animal contact.

Initial work up should include urine and blood cultures, CBC, CXR and CT head. HIV testing should be considered. A CT head followed by an LP (including bacterial culture and PCR for possible offending agents) should be performed and presumptive treatment with antibiotics and antivirals initiated while awaiting results. Viral encephalitis CSF is characterized by normal/high opening pressure, clear appearance, normal glucose, normal to high protein, and lymphocytes on the differential (early infection may show normal white cell count or elevated Neutrophils) (7).

Viral Encephalitis has an annual incidence of 5-10 per 100,000, more often affecting the young and elderly in areas with arthropod-borne viruses. Of these, HSV-1 is the most commonly diagnosed. Cases caused by Cytomegalovirus, Epstein-Barr virus, and human herpes virus (HHV)-6 are being encountered with increasing frequency because they occur in patients immunocompromised by HIV, cancer or transplant therapy. Arboviruses such as

West Nile virus and Nipah virus are causing outbreaks in geographically new areas while encephalitis caused by vaccine preventable viruses (measles and mumps) have declined in frequency (7).

Eastern equine encephalitis virus (EEEV) is an enveloped single-stranded RNA virus belonging to the genus Alphavirus within the family Togaviridae.

Several species of mosquitoes act as arthropod vectors of the virus, with wading birds acting as the reservoir. Culiseta melanura maintains the transmission between birds, which it mainly preys on. Bridging species such as Aedes, Coquillettidia, and Culex are responsible

mafpResident Grand Rounds

continued on page 13


SLAFP St. Louis Academy President Installed

In November, the St. Louis Academy of Family Physicians welcomed it's 2013 Board of Directors and expressed gratitude to outgoing president, Dr. Damon Broyles, for his service, and to long-time chapter executive, Vivian Helm, for organizing the installation event. As incoming president, I look forward to serving the family physicians of the St. Louis metropolitan area.

A few weeks prior to installation, I had the opportunity to attend the 2012 AAFP Scientific Assembly, a moving experience that I recommend at least once for any family physician who has not yet attended. While there, I heard Jeffrey Cain, AAFP President, outline three priorities for his presidential year:

1. ensure every American has a medical home,

2. secure fair payment for family physicians, and

3. ensure America's physician workforce is sufficient to meet the country's growing needs.

These goals are not only vital, but, I believe, also ultimately attainable. When asked what needs to happen at the ground level to make America's health care system work better, Dr. Cain responded, people "need to hear real-life accounts of family physicians and their patients." Dr. Cain was referring specifically to legislators and politicians but I think everyone needs to hear your daily joys and struggles with your patients, particularly community leaders and health care administrators, so that they can recognize the value of family physicians, and also medical students, so we can recruit and retain young family physicians.

I encourage SLAFP members to attend the Missouri Academy of Family Physicians 2013 Advocacy Day in Jefferson City on

February 26th to speak with your legislators about issues important to your practice and patients. I ask you to consider whom you could speak to within your local or hospital community regarding the same.

Now more than ever, family physicians are being called to be leaders. With one of its own members, Dr. Kate Lichtenberg, as president of MAFP, SLAFP is in a unique position to guide its membership into emerging leadership.

The SLAFP Board of Directors hosts it's first meeting of the year to discuss strategic goals supportive of AAFP and MAFP on January 9th at 6:30PM at St. Mary's Hospital. All members of SLAFP, including those living or practicing in St. Charles and Jefferson counties, are invited to attend. Be sure to check our website slafp.org for additional information regarding upcoming opportunities.

Sarah Cole, DO, Installed as 2012-2013 SLAFP PresidentSarah Cole, DO, FAAFPPresident, St. Louis Academy of Family Physicians

Do you need

CME?Mark your calendar!

Join us for the

65th Annual Scientific Assembly

to be held at

The Lodge of Four Seasons

Lake Ozark, MO

June 7- 9, 2013

Look for updates coming soon!www.mo-afp.orgwww.4seasonsresort.com


for transmitting the virus from avians to mammals. Humans and horses are considered dead-end hosts (6).

An average of 6 cases of EEE are reported per year in the US, mostly along the Atlantic and Gulf coasts. After an incubation period of 4 to 10 days, two types of illness may develop: systemic or Encephalitic. It is also possible that some people infected with EEEV may be asymptomatic. 4-5% of human infections with EEEV result in Eastern equine encephalitis (EEE); approximately one third of cases of EEE are fatal. People outside the age range of 15-50 seem to be at greatest risk for developing severe disease (6).

Systemic infection involves an abrupt onset of chills, fever, malaise, arthralgia, and myalgia lasting one to two weeks. Encephalitic symptoms develop a few days after systemic symptoms as discussed above. Patients who survive encephalitic illness may have long lasting or progressive mental and physical sequelae such as intellectual impairment, seizures, and paralysis (1).

Clinical suspicion stems largely from history, rapid clinical development of encephalitis, MRI findings as discussed above. Cerebrospinal fluid (CSF) findings include neutrophil-predominant pleocytosis and elevated protein levels with normal glucose. Brain lesions are typical of encephalomyelitis and include neuronal destruction and vasculitis, which is perivascular and parenchymous at the cortex, midbrain, and brain stem. There is minimal involvement of the spinal cord (occasionally the cervical spinal levels are affected). Diagnosis is confirmed from a positive result of any one of the following: Serum or CSF anti-EEEV IgM, Serum or CSF anti-EEEV IgG, PCR for EEE.

This is the first case of EEE in Missouri, illustrating the blurring of geographical boundaries associated with certain infections. It demonstrates the importance of taking a detailed history, examining the patient quickly, and having a high index for suspicion for unusual infections. Although there is no vaccine or treatment for EEE other than supportive measures, its diagnosis helps to avoid

unnecessary treatments/testing and guides public health precautions such as spraying endemic areas for mosquitoes.

1. Hirsch MS, et al. Case records of the Massachusetts General Hospital. Case 22-2008. A 52-year-old woman with fever and confusion. N Engl J Med. 2008 Jul 17;359(3):294-303.

2. Harvala H, et al. Case report: Eastern equine encephalitis virus imported to the UK. J Med Virol. 2009 Feb;81(2):305-8.

3. Hirsch MS, et al. Case 17-2003. A 38-year-old woman with fever, headache, and confusion. N Engl J Med. 2003 May 29;348(22):2239-47.

4. Lury KM, et al. Eastern equine encephalitis: CT and MRI findings in one case. Emerg Radiol. 2004 Aug;11(1):46-8. Epub 2004 Jun 10.

5. Calisher CH, et al. Identification of an antigenic subtype of eastern equine encephalitis virus isolated from a human. J Clin Microbiol. 1990 Feb;28(2):373-4.

6. Easter Equine Encephalitis. 2011. Center for Disease Control and Prevention. 12 Apr. 2012 http://www.cdc.gov/EasternEquineEncephalitis

7. Solomon T, et al. Viral Encephalitis: A Clinician’s Guide. Pract Neurol 2007; 7: 288–305

mafpResident Grand Rounds

Resident Grand Roundscontinued from page 11

Eastern Equine Encephalitis Virus Neuroinvasive Disease Cases Reported by State, 1964-2010

Do you need to be

published? Are you

interested in submitting your

report to be published as

a Resident Grand Rounds

article in our quarterly

Missouri Family Physician

magazine? Contact MAFP

Staff at (573) 635-0848 for

more information.

Attention Residents!


MAFP Tar Wars

Why do I teach Tar Wars?Susan Lentz, RN, BSNHolt County School NurseSouth Holt R-1 School, Oregon, MissouriMound City R-2 School, Mound City, MissouriCraig R-3 School, Craig, Missouri

Blair Oaks R-II Elementary School, Wardsville, MO, celebrated Red Ribbon Week from October 22-26, 2012. Red Ribbon Week promotes the education of anti alchohol, drugs and tobacco. To wear jeans for a day, the elementary teachers made a donation to the Missouri Adacemy of Family Physicians Tar Wars Program.

The elementary teachers presented the donation to Academy staff members on Thursday, October 25 at the school.

I have been a school nurse for 28 years. I am a firm believer that the habits you begin in your youth, you carry into adulthood. I am always in prevention mode, and two of my passions are teaching our students how to take care of their teeth (dental hygiene) and encour-aging them to be tobacco free.

I use the Tar Wars curriculum when I do my tobacco education the the 5th grade. Components of the program address issues the students of that age group can relate to:• the cost of tobacco - what could I buy

instead!• short term effects of tobacco - how will

this affect me now and in 10 years?• why smoke? - students verbalize lots of

misconceptions here• advertising - discussions help them

understand the untruthsTobacco use is a concern in my county. One point I stress to

the students is to NEVER START, because as they tell their family stories, they understand how hard it is to quit, and that nicotine addition will control your life. The Tar Wars curriculum is easy to use, and all the basic points presented are easy to expand on if time allows. When we discuss why people smoke, it is a good time to pres-ent ways to get out of peer pressure situations. Talking about the cost of tobacco is a real eye opener to them. I encourage them to take a stand against tobacco use, even if they are standing alonge. We talk about second-hand smoke and the harm it causes.

I don't know exactly when I began using the curriculum, but I

know I have been using it every year since 1998, because we had a state poster winner that year! We always do the follow up poster contest, designing posters that deliver a clear and positive message to be/stay tobacco free. Over the years our post-ers that all the students have designed have hung in various places:

school cafeteria, local businesses, local doctor's offices, and school hallways. It encourages the younger students, and sends a message to the community. It is a team approach, classroom teachers al-lowing time for me to teach the Tar Wars curriculum, and art teachers allowing art

time to create their posters at school.The three school districts I work for all have also been in-

volved in the Smokebusters program. Our school campuses are tobacco-free, with metal signs around the exteriors of the campuses promoting a tobacco free lifestyle. Our local health department has provided me with additional materials to use in tobacco education, which has been a big help.

As nurses/educators we strive to promote and model healthy behaviors. If I keep a student from using tobacco, in any form, through my efforts, then the time was definitely well spent! Thank you Tar Wars and the Missouri Academy of Family Physicians for all your efforts!

Pictured above, left to right: Susan Lentz, RN, Jamison Liles, 2012 Missouri Tar Wars poster contest winner, and Carolyn Pyeatt, Craig R-3 School 5th/6th grade teacher.

Local teachers donate to State Tar Wars Program

Become involved. Volunteer at your local schools and present Tar

Wars during its 25th year!


mafpNominate Family Physician of the Year

Nominate the 2013 MAFP Family Physician of the YearDo you have an outstanding, caring colleague or physician in your community that deserves the title “Missouri Family Physician of the Year?"

The Missouri Academy of Family Physicians (MAFP) supports over 1,100 active members in the work-force ~ doing extraordinary things every day. You know them, and we would like to acknowledge them.

MAFP is now seeking nominations for this prestigious award. Nominate your family physician or a family physician that you know!

Nominations may be made by any member of the MAFP or the public.

Visit our website at www.mo-afp.org to find everything you need:

• Nomination Form• Nomination & Selection Process• Past Winners• Judging Criteria• Eligibility Requirements & Limitations

You may also request information by calling MAFP at (573) 635-0830 or by emailing [email protected] .

The winner will be honored at the MAFP Annual Meeting in June 2013.

(Mail, fax, e-mail or online submissions are accepted)

Nominations due by March 1, 2013


MAFP Members in the News

Brig. Gen. John Owen, MD, a decorated military leader, recently received the Univeristy of Missouri - Columbia School of Medicine Alumni Achievement Award. Owen is a practicing physician at the Liberty Clinic in Liberty, Mo. He recently retired from his post as the Air National Guard Assistant to the Command Surgeon, Air Mobility Command. Owen received the Surgeon General’s Air National Guard State Air Surgeon of the Year award in 2007 and the Harry Truman Public Service Award in 2012. Owen served the State of Missouri as director of the Joint Staff, Missouri Joint Force Headquarters. He has received many honors for his service, including the Legion of Merit, the Global War on Terrorism Service Medal, the Air Force Commendation Medal and the Armed Forces Expeditionary Medal.

Brig. Gen. John Owen, MD

On Tuesday, Oct. 30, 2012, Dr. Mehmet Oz gave Kansas City a "15 Minute Physical" in partnership with HCA Midwest Health System, Alere, Inc. and Practice Fusion at the Research Medical Center Brookside Campus. Kansas City citizens were screened for blood pressure, cholesterol, glucose, weight and waist size. The segment aired on December 13, 2012 when Research Family Medicine Residency Program Director Steve Salanski, MD appeared before the studio audience. To view the episode, visit www.doctoroz.com and search for "Dr. Oz's Lifesaving Free Clinics, Pt 4." Salanski appears at the 6:30 mark.

MAFP President Kate Lichtenberg, DO, installed Sarah Cole, DO as St. Louis Academy of Family Physicians (SLAFP) President on November 24, 2012 (see

inset). Pictured above, front row (left to right): Secretary Edina Karahodvic, MD; Vice President Andrea Baxter, MD. Back row (left to right): Past President Damon Broyles, MD; Treasurer Joule Stevenson, MD; President-Elect David Schneider, MD; President Sarah Cole, DO.

SLU FMIG Executive Board members are pictured above, left to right: Allie Grither, Tanya Sylvester, Maddie Ripa, Sruti Surugucchi, and Clare O'Hare.

Saint Louis University FMIG hosted their first Procedure Night for first-year students where Christine Jacobs, MD, Family Medicine Residency Director and FMIG advisor, taught residents how to test vitals, respiratory capacity and suturing (see photo below left). They also hosted a Student Group Fair for the first year students where they recruited members for FMIG and AAFP. They realized that by recruiting directly during the fair, they were able to almost double intitial numbers from last year.

To date, they have hosted introductory talks to Family Medicine as well as the Patient Centered Medical Home. They are in the process of planning a second year Procedure Night by partnering with Mercy Hospital in St. Louis in which their residents and faculty members demonstrate basic ObGyn screenings and procedures. Also, they are planning to design a "Guide to 3rd Year" series in the spring in which they will host a talk on how to write SOAP notes, how to survive clerkships, and have a specialty speed-dating event to introduce the different clerkships.

SLU FMIG News:


mafp2013 Advocacy Day

Now you can provide a complete allergy testing and immunotherapy service line.

Your patients no longer have to suffer from seasonal allergies and you don’t have to risk losing them by referring out to specialists. By offering this service line, physicians are able to provide a higher level of care to a large portion of their patient base, while generating a new revenue stream.

• WehireandtrainaCertifiedClinicalAllergy Specialist to test, educate and custom build immunotherapy under the supervision of the on-site physician.

• Provideallsuppliesandmaterialsrelated to the service line.

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• Allowyoutotreatallergypatients rather than cover their symptoms with medications.

About United Allergy Services:

Interested in becoming a UAS Allergy Center? Visit www.UnitedAllergyServices.com or call 888.50.ALLERGY.

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Advocacy DayFebruary 26, 2013

State CapitolJefferson City

You can make a difference

Schedule:7:45am-8:45am BuffetBreakfast&Briefing~CapitolPlazaHotel9:00am-12:45pm LegislativeVisits~StateCapitol1:00pm-3:30pm LunchandBoardMeeting~CapitolPlazaHotel

Bring a colleague & join fellow MAFP Members (Actives,

Residents, Students, etc.) to promote the importance of

family medicine & primary care. This is your opportunity to

educate your State Senator & State Representative on issues affecting you, your profession, and your patients. MAFP Staff

will schedule the appointments for you with your legislators.

It's easy - all you have to do is register! Questions? Call MAFP at (573)635-0830oremail:office@

mo-afp.org.

http://www.mo-afp.org/Advocacy.htm


MAFP externship experiencemafp Congress of Delegates

This Congress went very smoothly and was one of the least contentious congresses that we’ve seen in some time. The one issue that garnered much debate and testimony and many very personal and emotional appeals was the Declaration of Support for Civil Marriage for same gender couples. After prolonged testimony during the reference committee and prolonged debate on the floor this issue was finally called to a vote. Despite the fact that your delegates voted according to the wishes of our membership, this motion narrowly passed. The resolve read that the AAFP supports civil marriage for same-gender couples to contribute to overall health and longevity, improved family stability and to benefit children.

Another issue that garnered a moderate amount of debate was ending age restric-tion with emergency contraception. This measure passed quite easily, reading that the AAFP advocate for emergency contracep-tion to be available over the counter to all women of reproductive age. Another item that passed was that the AAFP advocate for multiple pathways to enhanced payment for Patient Centered Medical Homes (PCMH). This was due to concerns about the exclu-sive reliance on the National Committee for Quality Assurance.

Another interesting item that was referred to the Board of Directors was to encourage the Veteran’s Administration to extend VA pharmacy pricing to prescrip-tions written by community providers car-ing for veterans as long as those medications are available on the VA formulary.

Passed was resolve that the AAFP develop and actively support a plan for model legislation that supports the right of primary care physicians to collectively nego-tiate with health insurers and grants them immunity from anti-trust statutes when they do so.

Referred to the Board was a resolve that the AAFP encourage and lobby for the enactment for an IRS-approved federal tax

credit of at least 75% for primary care physi-cians who locate or are located in a federally defined rural or medically underserved shortage area.

Addressing members concerned about the cost of becoming a designated Patient Centered Medical Home a resolve was passed that the AAFP seeks relief from the burdensome and non-value added payer requirements in the prescribing of diabetic supplies.

Other items that were passed are the AAFP make available to all constituent chapters specific funding for a new physi-cian delegate to attend the National Confer-ence of Special Constituencies (NCSC) con-sistent with and in addition to the current funding available for the constituent chap-ters to send representatives to the Annual Leadership Forum (ALF) and NCSC. Also, to help members deal with social media, a motion was passed that the AAFP develop guidelines or toolkit for family physicians’ professional use of social media.

A special moment during the Congress was when one of our esteemed members, Betsy Garrett, MD, received the Thomas W. Johnson Award for outstanding perfor-mance in teaching family medicine.

The outcome of this year’s elections: Aaron Meyer of St. Louis is the student board member; new members elected to the Board of Directors include Clif Knight, MD, of Indiana, Lloyd VanWinkle, MD, of Texas and Carlos Gonzales, MD, of New Mexico; elected to take Dr. Wood’s remain-ing two-year term was Rebecca Jaffe, MD, of Delaware. As I’m sure most of our mem-bers know by now, Julie Wood, MD, has resigned her position on the AAFP Board to assume the office of Vice President for Health of the Public and Interprofessional Activities, the office previously held by Dan Ostergaard, MD. This is quite an exciting move for Julie and we wish her all the best in this new frontier. The new president elect is Reid Blackwelder, MD, of Tennessee.

Next year’s candidates that have an-

nounced so far include: for the board: Mike Munger, MD of Kansas, Robert Lee, MD of Iowa and Jack Chow, MD of California; for president elect: Robert Wergen, MD of Nebraska, Barbara Doty, MD of Alaska and Rick Madden, MD of New Mexico.

Respectively submitted,

Bruce Preston, MD, Delegate Larry Rues, MD, Delegate

Darryl Nelson, MD, Alternate Delegate Kate Lichtenberg. DO, Alternate Delegate

(temporary for this year)

Addendum:There was concern expressed that the

costs and stress of obtaining PCMH certi-fication could put some smaller practices at financial risk, especially since reimburse-ments for the ADDED value of PCMH are still not well established in most insurance markets.

It was also noted that PCMH does seem to be working in many areas.

The Primary Care Patient Centered Collaborative recently published a sum-mary of the early PCMH experiences: “The Benefits of Implementing the PCMH, a Review of Cost and Quality Results.” This report can be found at the PCPCC excellent website- http://www.pcpcc.net/files/ben-efits_of_implementing_the_primary_care_pcmh.pdfThe

(In this report it’s important to see the tables, not just the exec summary).

The tone of the meeting from our lead-ers is that the time for Family Medicine is NOW. There will be substantial changes pro-posed in both reimbursement and in HOW healthcare is delivered in more efficient manner. Family Phys must be informed, get involved and be insistent that they have a voice in this process. While it is generally agreed that quality primary care must be the base of any viable healthcare system, we FPs need to insist that adequate reimbursement is the key to making this happen.

AAFP Congress of Delegates Philadelphia, PennsylvaniaOctober 15-17, 2012

Photo provided by LBJ Images


MAFP Needs Assessment Survey Coming Soon

Seeking Physician Volunteer for Asthma Ready® Community Workgroup

SponsorsMissouri Beef Industry CouncilMissouri Professionals Mutual (MPM)

ExhibitorsAbbottAmgenCitizens Memorial HospitalCorizonCox HealthDocs Who CareGenzyme A Sanofi CompanyHealth Diagnostic Laboratory, Inc.Home State Health PlanIdeal ProteinKowa Pharmaceuticals AmericaMedtronic: Deep Brain Stimulation DivisionMedtronic: Spinal DivisionMerck & Co., Inc.Mercy Clinic Physician RecruitmentMissouri Army National GuardMissouri Beef Industry CouncilMissouri Primary Care AssociationMissouri Professionals Mutual (MPM)MMIC GroupMSMA Insurance Agency, Inc.Novo Nordisk, Inc.PDS CortexPfizer, Inc.PrimarisSaint Louis University HospitalSanofi Pasteur: Vaccine DivisionSanofi Pharmaceuticals US - DiabetesSkaggs Regional Medical CenterSt. Jude Children’s Research HospitalTakeda PharmaceuticalsU.S. Army Healthcare Recruiting TeamUniversity of Missouri: Dermatopathology Services & Dermatologic and Mohs Surgery ServicesUniversity of Missouri: Department of Health Psychology

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Over1,200 Family Medicine jobsAnd thousands of qualifiedcandidates

State legislation passed in 2012 relating to schools stocking "Asthma-related rescue medications." The intent is for any student experiencing a life-threatening asthma exacerbation may have medication administered by a school nurse or trained staff. Asthma Ready® Communities is seeking physician input as they aim to develop guiding treatment protocols, inform and support provider and pharmacist roles, support school nurse role, and training for school nurses and designated school staff. Please contact: [email protected] if interested in providing input.

2012 Annual Fall ConferenceSponsors & Exhibitors

How do you utilize the MAFP website and what value do you place on our current website, magazine, social media, email blasts and all other communications? We would like to make changes but need your input first! Please be on the look-out for an electronic request to complete upcoming Needs Assessment Survey.

From one champion to another: Join us! We welcome the opportunity to be of service to you. ContaCt managing direCtor timothy h. trout at 314.587.8000 or visit mpmins.Com

We know some of the greatest medical professionals in the world reside and practice in the state of Missouri. And that is why we are happy to be recognized yet again as Missouri’s #1

medical professional liability insurance company.

For ten years we have been proud to serve each and every one of our insureds, offering actuarially and financially sound insurance with over 400 years of combined experience

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Our promise to you– we will constantly strive to be the best at what we do so you can focus on what you do best: practice medicine.

in Missouri

missouri family physician magazine jan-mar 2013

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