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MISSOURI

Official Publication of the Missouri Academy of Family Physicians

Family Physician

July-September 2013 Volume 32, Issue 3

Meet MAFP President William Fish, MD pg. 16

Resident Grand Rounds Anjani Urban, MD Sarah Cole, DO pg. 10

Family Physician of the Year R. Aron Burke, MD pg. 14

Resident Grand Rounds Mark Mueller, MD Aaron Gray, MD pg. 24


Contents MAFP

Mark your Executive Commission Board Chair - Kate Lichtenberg, DO, MPH (Kirkwood) President - Bill Fish, MD (Liberty) President-elect - Daniel Purdom, MD (Kansas City) Vice President - Peter Koopman, MD (Columbia) Secretary/Treasurer - Tracy Godfrey, MD (Joplin)

Calendar

AAFP NCFMRS August 1-3, 2013 KC Convention Center, Kansas City, MO

AAFP Board Review Express Live Course October 2-5, 2013 See pg. 9 St. Louis, MO

Board of Directors District 1 Director: Dana Granberg, MD Alternate: Jennifer Moretina, MD District 2 Director: Lisa Mayes, DO Alternate: Vacant District 3 Director: F. David Schneider, MD Director: Vacant Alternate: Caroline Rudnick, MD District 4 Director: Vacant Alternate: Vacant District 5 Director: James Stevermer, MD, MSPH Director: Vacant Alternate: Vacant District 6 Director: Jamie Ulbrich, MD Alternate: Vacant District 7 Director: Kathleen Eubanks-Meng, DO Director: George Harris, MD, MS Alternate: Vacant District 8 Director: Mark Woods, MD Director: John Paulson, DO, PhD Alternate: Vacant District 9 Director: Charlie Rasmussen, DO Alternate: Vacant District 10 Director: Mark Schabbing, MD Alternate: Steven Douglas, MD

AAFP Congress of Delegates September 23-25, 2013 Marriott Marquis and Marina, San Diego, CA

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

Resident Directors Suzan "Annie" Lewis, DO Imani Anwisye, MD (Alternate)

4

CME?

Join us for the 21st Annual Fall Conference and SAM Study Group to be held at Big Cedar Lodge, Ridgedale, Missouri

November 8-10, 2013

www.bigcedar.com

Early bird discount and Room Reservation deadline end 10/07/13

Visit www.mo-afp.org • Registration Form • Room Reservation Form

• Schedule of Events

Inside this issue 7

Officer Reports & Annual Reports

20 Legislative Session Update

Pat Strader, MAFP Governmental Consultant Needs Assessment Survey Results are in 24 Resident Grand Rounds Kate Lichtenberg, DO, MPH, FAAFP

Student Directors David Kramer Amanda Williams (Alternate)

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AAFP Delegates Larry Rues, MD Darryl Nelson, MD Bruce Preston, MD (Alternate) Keith Ratcliff, MD (Alternate) MAFP Staff Executive Director - Jennifer Bauer Education & Finance Director - Nancy Griffin Managing Editor/Member Services - Laurie Bernskoetter Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p (573) 635-0830 www.mo-afp.org

Register online now!

Do you need

f (573) 635-0148 office@mo-afp.org

Family Health Foundation Celebrates 25 Years

Mark Mueller, MD Aaron Gray, MD

26 ASA Exhibitors

2013 MAFP Family Physician of the Year Finalists 2 10 Resident Grand Rounds 4

Advertisements

14 Family Physician of the Year

St. Luke's Neuroscience Institute Symposium

5

National Dairy Council

8

Missouri Health Professional Placement Services

9

AAFP Board Review Express™ Live Course in St. Louis

7

Anjani Urban, MD & Sarah Cole, DO R. Aron Burke, MD

15 Membership Anniversaries 16 Welcome New MAFP President William Fish, MD

18 Family Medicine Congressional Congress

Aaron Whiting, MD, Brandon Luk, MD, & Drew Glover, MD

20 Legislative Session Update

Cox Health

13 Saint Louis University FMC Job Opportunity 23 HEALTHeCAREERS 26 United Allergy Services

Pat Strader, MAFP Governmental Consultant 28

Missouri Professionals Mutual (MPM)

Missouri Family Physician July - September 2013

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MAFP Officer Reports

Todd D. Shaffer, MD, MBA, FAAFP 2012-2013 MAFP Board Chair

T

he Missouri Academy of Family Physicians has completed 65 years of membership benefits this year including great education and advocacy for primary care in Missouri. We have been so fortunate to have such a talented group of executive officers that will continue to advance our organization. Our President Dr. Kate Lichtenberg will be a great board chair next year helping to finish out our 5 year strategic plan that we have completed so much on. Measuring primary care workforce for the state is the last “Rock” left to be completed in the next year before moving on with developing the next 5 year plan. We look forward to Dr. Bill Fish being installed as the next president of the MAFP this weekend. Dr. Dan Purdom will bring his expertise of community health to the office of president elect for the next year. Dr. Tracy Godfrey will continue her great work with our budgeting and spending as our Treasurer. Our commissions have been racing along with Drs. Arthur Freeland and Keith Ratcliff leading the advocacy efforts statewide. Lots of great work and connections have helped our physicians and their patients to ward better primary care efforts across the state. Payment reform and tort reform will continue to be the big topics also with Mid-level providers wanting to expand their independent practice. Recently their education level has been compared to letting 2nd year medical students loose without proper oversight and will have to continue to be the message we are sending to the capital and the state. We love working beside them in teams, but continue to believe that what is best for our patients is a completely trained broad spectrum primary care physician with the proper oversight. Our planned legislative day in 4

Jefferson City was cancelled due to the left half of the state being inundated with up to 16” of snow. We had to cancel last minute and a smaller day was made up later to voice our message to our representatives. Pat Strader continues to work as our eyes and ears for day to day issues in the State Capitol. The Missouri Academy was honored as Aaron Meyer (Medical Student form SLU) was elected as the student Rep to the AAFP board. Such a great honor for Aaron and our state academy! He has represented us well nationally and ever so strongly at the Family Medicine Congressional Conference (FMCC) in Washington DC that we recently attended. To my knowledge, we had a larger contingent than ever before. Our Academy sponsored three residents to attend; we had two students, Dr. Koopman and myself, Jen Bauer as our executive Director and three AAFP staff who happen to live on the Missouri side. It was great to see 11 for Missouri in the national spotlight in DC. The Education Commission led by Drs. Peter Koopman and James Stevermer has done excellent planning our education offering of our state and we know they will continue to show their efforts as we move forward with future meetings. I have been amazed at how well my time on the board has weathered many storms. Continued growth in Membership and assets of the academy through a down economy over the past few years is now stronger than it has ever been. I want to thank all members of the academy and the board for all your individual and team efforts for the future of our academy. We are always looking for members’ talent and time to give back to the organization that does so much for the more than 1,900 members and their patients. I look forward to the next years graduates of our residency

Missouri Family Physician July - September 2013

programs entering practice in our state and ever more glad about the newest of our future leaders for our academy. As I step away as a “Soaring Eagle,” I will continue to be involved with education in our academy and nationally. After 4 years as board member and as treasurer of The Association of Family Medicine Residency Directors (AFMRD), I was elected in April as President Elect to lead the program directors association in the upcoming changes to our Family Medicine training programs. I am excited for the challenge in this very dynamic and growing time of change for family medicine. I thank everyone who has supported me over the years and look forward to a stronger presence of FM in the future healthcare delivery structure for our country


Officer Reports MAFP

Kate Lichtenberg, DO, MPH, FAAFP 2012-2013 MAFP President

L

ooking back, it is hard to believe that my time as President for the Missouri Academy is coming to an end. It has certainly been an eventful year. From the Supreme Court upholding the ACA to the defeat of Medicaid expansion here in Missouri, it is enough to make your head spin at times. Your Academy has worked hard on your behalf. If you have a moment, please take time to thank our wonderful staff. Without Jennifer Bauer, Nancy Griffin, Laurie Bernskoetter, and our lobbyist Pat Strader, it would be even harder, if not impossible, to accomplish what we have. Our members are well represented at the Capitol. Despite our Advocacy Day

being snowed out this year, we did have some members who were able to attend a make-up day in April. We also had a great delegation from Missouri that attended the Family Medicine Congressional Congress in Washington DC in May. We will continue to advocate for our patients at the state level as well as the federal. Work force issues continue to come up in Missouri and around the country. Your leadership has been able to attend multi-state meetings where we are learning from other Chapters how we can go about advocating for the future of family physicians here. Thank you to all of our members around the state who take medical students in their offices and expose

them to the joys of taking care of our patients. Communication with our members remains a vital part of what we do. From our quarterly magazine to our bi-weekly Show-Me State Updates, we want you to know what is going on in your Academy. If you ever have feedback on how we can do better, please let us know. I would like to congratulate Dr. Todd Schaffer for his tremendous leadership and Dr. Bill Fish as he begins his term as president. On a personal note, I would also like to thank my husband, Mike, and my kids for their unending patience through meetings and phone calls. I couldn’t do any of this without their support!

Missouri Family Physician July - September 2013

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MAFP Officer Reports Vice President Report

President-elect Report During my two years as an officer on your board I’ve tried to become better informed on health care policy and I’ve attended a plethora of lectures on the changing health William Fish, MD, FAAFP care environment. I’ve enjoyed exchanging ideas with other physicians, legislators and lobbyists at AAFP’s Leadership Forum, their State Legislative Forum and the Midwest MultiState Legislative Forum. I’m impressed with the enthusiasm of family medicine’s leadership but sometimes I wonder, after hearing twenty talks, whether I have a better understanding, or worse understanding, of the inevitable changes we will face in the medical profession. I’m sure many of you find your heads swimming with the changes and how you should prepare, as well. I assure you your state academy is diligently working to keep up and keep you informed so you can do the same. Members of the MAFP board have seats on most of the committees making policy recommendations in the state and we regularly share insights gained from this participation. This isn’t a one way street, however. If you have ideas, concerns, or insights to share, please contact any of your board members or your academy staff. There are some issues upon which consensus is lacking, but there are many areas where we are nearly unanimous in opinions. These areas, such as lessening administrative burdens, tort reform, loan repayment and support of family medicine education are areas where we need an engaged membership. When asked to attend Advocacy Day, a friend of mine said «I don’t know want to know what goes into making a hot dog or making a law». True, neither is appealing, but we can’t afford to sit back and let our profession be directed by poor policy made by underinformed 6

or misinformed people. Advocacy is not a spectator sport. It is a tough, challenging, full contact endeavor. It is also fully participatory and we need engagement of our members to be successful in a very competitive process. We have a health care system that has gradually moved away from a successful, primary care dominated system to one which is now becoming costly, fragmented and heavily weighted in numbers to sub-specialty docs. Health care policy gurus universally express the need to reverse this trend. Given these supportive policy statements and the absolute necessity of slowing the rising costs of health care, we have an environment conducive to moving the behemoth our system has become in the right direction. But we can only do it with an all-out effort. We are all busy trying to see a burgeoning patient population and keeping our heads above water with administrative responsibilities, but continue to make time to participate in the process. Attend our advocacy meetings, read the legislative updates and give comment. If you have anecdotes related to any issue, let your leadership know. Personal stories make all the difference in a legislative committee room. If time constraints make it impossible to sacrifice time, then go to the MAFP web site and contribute something to your Political Action Committee. We had successes and failures in the recently concluded legislative session which will be reported on at the legislative luncheon and at the advocacy commission meeting. Join us in the coming year in working toward reinstatement of Missouri non-economic damage caps along with obtaining the other shared goals of family medicine. As your board, we view the future of family medicine as very bright. We are looking at the changes to come as a challenge and an opportunity to advocate for efficiency and quality, and not as an opportunity to retire. We hope you’ll do the same.

Missouri Family Physician July - September 2013

“May you live in interesting times!” I have heard this described as both a Chinese blessing and as a curse. We certainly live in interesting times. The Affordable Care Act was Dan Purdom, MD, FAAFP upheld in an incomplete form, the Missouri legislature did not vote to expand Medicaid coverage and we had the usual fights in the Missouri State Assembly over scope of practice for non-physician providers. I was fortunate enough to attend the Multistate Forum this year in Dallas. This is a great meeting for Family Physicians to come together and exchange legislative and payer updates. Not surprisingly, what FPs have seen in one state is a strategy that shows up in other states. Sharing this information helps all of us to be better prepared for the times ahead. My year as your vice-president has truly been interesting.

Secretary/Treasurer Report "...MAFP is dedicated to optimizing the health of patients, families, and communities of Missouri through patient care, advocacy, education, and research." Tracy Godfrey, MD MAFP has a tradition of providing its members with the resources to accomplish this mission. I am pleased to share that this has been done within the approved 2013 budget. Thanks to the Board of Directors and the MAFP staff for all the hard work that made it happen.


Annual Reports/Survey Results MAFP Member Services Commission Report As an organization, the Missouri Academy of Family Physicians strives to offer members benefits which are current, relevant and of importance to you. To do so, we rely on input from you – our members. Please contact your district leaders or MAFP staff with any suggestions and/or comments regarding ways in which we can improve our service to you. During the 2013 AAFP ALF/NCSC, MAFP was presented the AAFP 2012 Full Delegation to NCSC and the AAFP 2012 Award for 100% Resident Membership. In 2013, we join our MAFP members celebrating AAFP and/or MAFP membership anniversaries. Those who attended the Annual Scientific Assembly were recognized at the Awards and

Installation Dinner. A full listing of the Membership Anniversaries for 2013 are included in this issue. (See page 15)

†Raymond G. Elliott, MD (Kansas City, MO) †Carl R. Kruse, MD (Hannibal, MO)

Necrology Report (April 2012 to April 2013)

†Robert R. Lyle, MD (Versailles, MO)

†Alexandar Arsenovic, MD (Ware Neck, VA)

†Walter J. Stelmach, MD (Kansas City, MO)

†John E. Bennett, MD (Columbia, MO)

†Sharon E. Waggoner, MD (St. Joseph, MO)

†Albert J. Campbell, MD (Raleigh, NC)

†Alan G. Zond, DO (Florissant, MO

†Herman P. Ekern, MD (Mexico, MO)

According to an April AAFP 5-Year MAFP Membership Overview Report and comparison, our MAFP chapter, which is categorized as a large chapter, does not follow AAFP national trends. Active Member Retention - The AAFP rate of Active member retention saw a two-year decline from 2007 through 2009 of 2.1%. After an increase of 1.5% from 2009 to 2011, the AAFP dropped just slightly down to 95% in 2012. MAFP does not follow AAFP national trends, showing a 0.6% decrease from 2009 to 2011. Our chapter saw a large increase of 2.1% from 2011 to 2012, unlike the decrease that AAFP experienced.

Survey Results are in by Kate Lichtenberg, DO, MPH, FAAFP We asked; you responded. Results from our needs assessment survey: MAFP sent out an electronic survey a few months ago to poll our members and get a better sense of where we need to use our resources. Statewide legislative advocacy topped the list with nearly 50% of respondents telling us that was very valuable. Involvement in leadership on issues that are important to family physicians came in at a close second.

Almost 78% of those responding stated they either agreed or strongly agreed that they were satisfied overall with MAFP. While those numbers are encouraging, we would like to see them even higher and will be working toward that goal. We are currently reworking our website with a goal to launch that this fall. Our survey indicates that 46% of our respondents rarely visit our current website. Be on the lookout

for our enhanced site coming soon. We are always looking for feedback to improve our services. Several comments being made on the recent survey are actively being looked at by our Member Services Commission. But don’t feel you have to wait for a survey to give us your suggestions. Please contact Laurie Bernskoetter, our MAFP Member Services Coordinator, at (573) 635-0830.

Missouri Family Physician July - September 2013

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MAFP Annual Reports Resident Report

Suzan Lewis, DO

Imani Anwisye, MD, MPH

ASA Conference attendance: At ASA in June, MAFP hosted three residents and five students. Twelve posters were submitted by residents. Visit page 27 for poster contest winners. Match Results: At the match this year in March, Family Medicine residency programs filled 2,938 positions of the 3,062 offered, for a fill rate of 96.0%. This is 1.5% higher than last year’s figure, and there were 298 additional positions in this year’s match, which included FMpsych, FM-EM and FM-IM. Overall, the percentage of US medical school seniors who chose family medicine decreased from 8.5% in 2012 to 8.4% this year. (Statistics from the AAFP).

• Kirksville – 2 • Loma Linda University – 1 • Des Moines University – 1 University of MO-Columbia FMR - 12 residents • MU – 6 • Southern Illinois University – 2 • Oklahoma State University – 1 • University of Nebraska – 1 • University of Arkansas – 1 • Ross University – 1

Match 2013 - where they came from: Research FMR – 11 residents • KCUMB – 5 • KU – 4 • American University of Antigua – 1 • Saba University – 1 UMKC FMR - 14 residents • KCUMB – 5 • St Louis University – 2 • University of MO Colombia – 2 • University of Kansas – 1 • Des Moines – 1 • AT Still – 1 • University of Nebraska – 1 • Ross University – 1 Cox FMR - 8 residents • University of MO Columbia – 2 • University of Arkansas – 2 8

Missouri Family Physician July - September 2013

St. Louis University FMR – 4 residents • St Louis University – 2 • Washington University STL – 1 • University of MO Columbia – 1 Mercy FMR - 6 residents • Saint Louis University – 4 • University of Oklahoma College of Medicine at OKC – 1 • AT Still University - Kirksville College of Osteopathic Medicine – 1


Annual Reports/FHFM Anniversary MAFP

Celebrating 25 Years Improving the health of families in Missouri The mission of the FHFM is to support scientific, educational and charitable initiatives for the specialty of family medicine, and to improve the health of families in Missouri. In partnership with the AAFP Foundation, some of the ways the FHFM serve that mission are: offering summer externships that give students the opportunity to work with practicing family physicians; awarding student scholarships for outstanding graduates who have matched with a family medicine residency program; supporting the Tar Wars program; and funding scholarships for residents and students to attend national family medicine conferences. FHFM is a 501 (c) (3) charitable corporation and contributions are tax deductible. Fundraisers FHFM still has EVERYONE DESERVES A FAMILY PHYSICIAN license plate frames available for purchase for $10. FHFM is seeking input and ideas for future fundraisers. ASA Student/Resident Sponsorships FHFM would like to thank James Stevermer, MD for his contribution to offset costs for students/residents attending this year’s Annual Scientific Assembly. Scholarships Five top graduating medical students who are entering family medicine residencies were awarded certificates and scholarships of $500 each. The family medicine scholarships were awarded to:, Isaac Sparks, A.T. Still; Bethany Davis, Washington University; Nicholas LeFevre, UMC; Jennifer Rose Callison, KCUMB; and Aaron Meyer, SLU. Summer Externships With AAFP Foundation matching funds, the FHFM sponsors four-week summer externships. This year, KCUMB Student Daniella Boyer (UMKC FMR), UMKC

Student Jenny Eichhorn (Research FMR), UMKC Student Kevin Gray (UMKC FMR) and SLU Student Michele Wong (Mercy FMR) are participating. Tar Wars Tar Wars continues to be a very successful program. This year’s poster contest had over 25 submissions and the Missouri Tar Wars poster winners were: 1st Place: Monique Arroyo, South Holt R-1 School St. Joseph, MO 2nd Place: Rhett Hall, Mound City R-2 School Mound City, MO 3rd Place: Rachel Szala, St. Therese School Kansas City, MO 4th Place: Claire Russell, Blair Oaks Elementary School Jefferson City, MO 5th Place: Logan Tracy, Santa Fe Elementary School Waverly, MO The first place winner will travel to Washington, DC in July to participate in

the Tar Wars National Poster Contest and also received a check in the amount of $100. Checks in the amount of $50 each were awarded to second and third place poster winners. Fourth and fifth place winners each received a gift card in amount of $25 donated by Central Bank. Donate to FHFM today! Your generous donation will help support: • Sponsor students to attend the MAFP Annual Scientific Assembly in June • Sponsor student/resident scholarship to NCFMRS • Sponsor medical student scholarships • Sponsor Summer Externship Scholarships • Support Tar Wars® Program

Visit www.mo-afp.org/foundation.htm for more information and to complete online donation form.

How to Pass Your Boards Prepare to pass your ABFM Boards with comprehensive, evidence-based live course developed by and for family physicians. AAFP Family Medicine Board Review Express™ Live Course in St. Louis Attend a three-and-a-half day live course with your colleagues to review the evidence-based principles of family medicine and learn effective test-taking strategies. Register today at w w w.aafp.org/brestl. As an AAFP Member, you can save big on Board Review resources from the AAFP. Missouri Family Physician July - September 2013

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MAFP Resident Grand Rounds

Incontinentia Pigementi: An Unusual Rash in a Neonate Anjani Urban, MD and Sarah Cole, DO Mercy Clinic Family Medicine - St. Louis Case BH, a 3 day old female presented to the family medicine center (FMC) for a routine weight check. Born at an outside hospital, the infant’s mother reported an uncomplicated pregnancy and delivery. BH’s mother was positive for herpes simplex virus (HSV), however her last outbreak was four months prior to delivery. Her mother had no other known exposures to teratogenic infections, pharmaceuticals, or chemicals. At nursery discharge on day 2 of life, the infant had a 5% loss from birth weight of 3.35 kg and was reported to have a slate gray rash on her buttocks consistent with pustular melanosis. She was otherwise stable. Since discharge, her mother denied feeding difficulties. BH had a weight of 3.15 kg. She was noted on exam to have a rash on her face, limbs and trunk consistent with pustular melanosis. Reassurance was provided on the benign nature of the rash. At 10 days of age, the infant returned to the FMC for complaint of rash. Her mother reported that after her last visit, the rash appeared to flare with vesicles across her trunk and extremities. Over the course of the next few days, vesicles would develop in various areas, crust over, and resolve. BH remained afebrile with normal appetite, energy, and diapers. Her weight had increased to 3.32 kg. Physical examination of the infant revealed a

Figure 1

Anjani Urban, MD

papulovesicular rash on the trunk, flexor surfaces of the arms, ventromedial surfaces of both legs, and scattered lesions with an erythematous base on the right shoulder with hyperpigmentation (Figure 1). A single 5 mm vesiculobullous lesion was noted on the left leg (Figure 2). The mother denied family history of neonatal rashes or other birth defects. As the patient showed no signs of ill health, watchful waiting was recommended. At 14 days of age, she returned with a repeat flare of the rash. She remained afebrile (97.9F) with adequate weight gain (3.86 kg). Although there was low suspicion for HSV due to the patient’s nontoxic appearance, one vesicle was unroofed and yellow fluid was collected and sent for viral culture. Due to the puzzling clinical picture, the patient was referred to dermatology. During dermatologic consultation, her mother related that recent conversations with BH’s maternal grandmother revealed a family history of frequent miscarriages. She also described a fine lacy hypopigmented rash in multiple female relatives, assumed by the family to be harmless. Many of these women, including the patient’s mother and maternal grandmother, developed monocular blindness and poor dentition during childhood. Based on this family history and the patient’s presentation, the dermatologist diagnosed the infant with incontinentia pigmenti (IP).

Figure 2 10 Missouri Family Physician July - September 2013

Discussion IP is a rare X-linked dominant disorder characterized by

Sarah Cole, DO

dermatologic, ophthalmologic, neurologic, and dental abnormalities. Diagnosis is largely based on clinical features. It is estimated to occur in approximately 1 in 50,000 newborns. Affected infants are largely female as the disorder is fatal in most males in utero.1 The few surviving male infants either have de novo postzygotic mosaicism of the X chromosome, hypomorphic alleles with minimal gene function, or Kleinfelter’s syndrome (XXY).2 IP is caused by a mutation in the nuclear factor KB essential modulator gene (NEMO) on chromosome Xq28. This gene mutation leads to dysplasia in the development of the ectoderm, the embryologic precursor of skin, brain, eyes, and teeth.3 The characteristic dermatologic features of IP include a series of typical rashes that tend to follow along the lines of Blaschko (Figure 3). The rash evolves in four classic stages that can appear concurrently or sequentially. Stage one involves erythema and vesicles. Stage two involves development of verrucous lesions (Figure 4). In stage three, the skin develops

Figure 3


Resident Grand Rounds mafp

Figure 4

Figure 5

linear hyperpigmentation along the lines of Blaschko (Figure 5). Finally in stage four, pallor and scarring develop in the affected areas (Figures 6, 7). Patients may also demonstrate alopecia of the vertex or nail dystrophies.4 The skin manifestations themselves are relatively benign. More debilitating are the ocular manifestations, which can occur in up to 30% of patients.5 A meta-analysis encompassing over 1,900 patients with ocular manifestations of IP documented that the most common ocular anomalies were retinal in nature. Retinal detachment occurred during early childhood, in many cases likely caused by retinal vascular changes. Strabismus was the next most common finding, followed by amaurosis, lens anomalies, optic nerve atrophy, vitreous anomalies, and microphthalmus/ anophthalmos.6 These severe anomalies usually resulted in blindness or threats to vision. In addition, patients may develop cataracts, blue sclera, or nystagmus.5

Figure 6

Figure 7

characteristic cone or peg-shaped crowns can be found in IP. These abnormalities do not necessarily cause disability, but severe cases may require the assistance of dentists, orthodontists and/or prosthodontists.8 IP is a rare genodermatosis diagnosed based on a constellation of physical signs. The name incontinentia pigmenti and its dramatic dermatologic findings belie the potentially devastating effect that the

disease can have on a patient’s neurologic status and vision. Suspicion for this disease should prompt urgent referral to pediatric neurology and retinal specialists. As an X-linked dominant disease, families should be counseled that all conceived children have a 50% chance of inheriting this gene and that affected male offspring tend to succumb in utero. Further genetic counseling should be offered to families.

continued on page 13

The potential neurologic manifestations can be devastating to the patients and their families, occurring in about one-third of patients with IP. Ischemic infarctions can lead to hemorrhagic encephalopathy and necrosis of the brain, followed by widespread atrophy and cavitation. This can occur in the first days to weeks of life and can present as seizures, spastic paralysis, ataxia, motor dysfunction and death. Mental retardation is often noted during development.7 Dental anomalies occur in 50-75% of IP patients. While not apparent in the neonatal phase, they may aid in clinical diagnosis of the disease as part of the family history. Hypodontia (diminished number of teeth), delayed eruption, and

Figure 8 Missouri Family Physician July - September 2013

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MAFP Members in the News

Members in the news In May, the Institute for Family Medicine received a FOCUS St. Louis What’s Right with the Region! Award at Sheldon Concert Hall for "Demonstrating Innovative Solutions" to providing health care for St. Louis’ disadvantaged and underserved. The award honors organizations that have “made a profound difference in the St. Louis region." Founded by David Campbell, MD, the Institute for Family Medicine is a 12-year-old nonprofit organization with a mission to improve health and quality of life for disadvantaged children and families by reducing access barriers and delivering quality healthcare services. The organization partners with schools, shelters and other social service organizations to provide medical services to disadvantaged children, homeless teens and low-income families at already trusted points of service in their communities.

Kate Lichtenberg, DO, MPH, was recently named the physician director of the new Patient Centered Primary Care initiative at Anthem Blue Cross and Blue Shield in Missouri. In this role, Licttenberg will be responsible for leading patient-centered care strategies in Missouri and will work directly with network primary care physicians to assist them in their transition to patientcentered medical home practices. The Saint Louis University School of Medicine Family Medicine Interest Group was recently chosen as one of ten recipients of the AAFP 2013 Program of Excellence (PoE) Awards as an overall winner. The FMIG will be featured at the AAFP NCFMRS in Kansas City in August. For a listing of winners and publication of applicans, visit aafp.org/ poe.

University of Missouri - Columbia Family Medicine Resident, Emily Douchette, MD, has been selected to receive the 2013 AAFP Award for Excellence in Graduate Medical Education. Dr. Douchette is being recongnized for her outstanding performance during residency training. The award will be presented on Friday, September 27 during the AAFP Scientific Assembly in San Diego Congratulations to the following AAFP 2013 Scholarship and Program Winners for NCFMRS in Kansas City, August 1-3, 2013: • First -Time Student Attendee Award Stefanie Rademacher • Minority Scholarship Program for Medical Students Alishka Elliott • FMIG Leadership Award Andrea Schuster • Tomorrow's Leader Award Jennifer Allen, MD.

The University of Missouri-Columbia School of Medicine was recognized by the AAFP for the school's efforts to foster student interest in family medicine and contributing the most to the pipeline of family physicians. The school was one of 12 out of the nation's 126 allopathic medical schools to receive the 2013 AAFP Top Ten Award. Medical school faculty are pictured below accepting the award from AAFP President Dr. Jeffrey Cain at the award presentation which was held on May 3 in conjunction with the Society of Teacher's of Family Medicine meeting in Baltimore.

Pictured above, L to R: Steve Zweig, MD, Jeffrey Cain, MD, AAFP President, and Betsy Garrett, MD. 12 Missouri Family Physician July - September 2013

Pictured above, L to R: David Mehr, MD, Erik Lindbloom, MD, MSPH, Jeffrey Cain, MD, AAFP President, and Richelle Koopman, MD, MS.


Members in the News MAFP

Incontinentia Pigementi continued from page 11 Case Follow-Up The patient’s family was immediately referred to pediatric neurology and ophthalmology upon clinical diagnosis of IP. Neurologic evaluation was negative, however the neurologist urged the patient’s family to immediately seek care for any concerning neurologic symptoms. BH had no abnormalities on ophthalmologic consultation, but as the patient’s family had a history of monocular blindness, they were referred to a retinal specialist.

consultation was offered, but after multiple conversations with the primary physician about the disease, the family did not feel that such consultation would add to their understanding of the disease and its implications for future pregnancies. Viral culture of BH’s vesicular lesion was negative for HSV. As of 4 months of age, BH has met all developmental milestones and continues to exhibit normal red reflexes and ocular motion with appropriate gaze and focus.

2. 3. 4. 5.

6.

7.

BH’s mother and maternal grandmother provided a detailed family history documenting this disease through 5 generations (Figure 8). Genetic

Members in the News (continued) Advocacy Day 2013 (rescheduled) – Thank you to the physicians who rearranged their schedules to attend the April 23rd event. Jennifer Allen, MD (Mercy FMR), Sarah Cole, DO, David Kramer (KCUMB), Jason Mitchell, MD (AAFP), Keith Ratcliff, MD, David Schneider, MD, and Jamie Ulbrich, MD braved the cold, rainy day and traveled to the State Capitol to advocate for family medicine and their patients. Correction: in the Jan - Mar 2013 issue of the Missouri Family Physician (page 16), Brig. Gen. John Owen, MD, received the University of Missouri - Kansas City School of Medicine's Alumni Achievement Award. It was incorrectly listed as the University of Missouri - Columbia School of Medicine Award.

Send us your news! Email photos & text to lbernskoetter@mo-afp.org

References: 1. Thakur S, Puri RD, Kohli S, Saxena R, Verma IC. Indian J Med Res. Apr 2011; 133 (4): 442-445.

8.

Jabbari A, Ralston J, Schaffer JV. Derm Online Journal. 2010 16(11): 9. Florin TA, Shah KN. Arch Ped Adol Med. Apr 2011; 165(4):368-368. Hadj-Tabia S, Froidevaux D, Bodak N, et al. Arch Dermatol. 2003; 139: 1163-1170. Motamedi MH, Lottfi A, Azizi T, Moshref M, Farhadi S. Indian J Pathol Microbiol. 2010; 53:302-304. Minic s, Obadovic M, Kovacevic I, Trpinac D. Srp Arh Cel Lek. Jul-Aug 2010; 138(78):408-13. Goldberg MF. Arch Derm. Sep 2003; 140(6): 748-750. Doruk C, Bicakci AA, Babacan H. Angle Orthodont. 2003; 73(8): 763-766.

Job Opportunity FULL-TIME FACULTY CLINICIAN/EDUCATOR FAMILY MEDICINE CLINIC – County Health Center Saint Louis University, a Catholic, Jesuit institution dedicated to student learning, research, health care, and service is seeking applicants for a full time faculty position (Assistant Professor) in the department of Family and Community Medicine. A board certified family medicine physician with strong clinical skills and experience in care for the underserved is sought for a clinical practice at the Saint Louis County Health Center in South St. Louis County. This appointment will also include teaching of medical students, rounds at a community hospital for our family medicine residency program, and on-call duties. Salary is dependent on qualifications and experience. Application must be made online at http://jobs.slu.edu; application must include a cover letter and curriculum vita. In addition, applicants may send their curriculum vitae with an introductory letter describing their past experience and three letters of recommendation to F. David Schneider, M.D., M.S.P.H., Professor and Chair, Department of Family and Community Medicine, 1402 S. Grand Blvd., St. Louis, MO 63104, or via e-mail to dschne13@slu.edu. Calls with questions are welcome in the department, 314-977-8480. Review of applications begins immediately and continues until the position is filled. Saint Louis University is an affirmative action, equal opportunity employer, and encourages nominations of and applications from women and minorities.

Missouri Family Physician July - September 2013

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MAFP Family Physician of the Year

R. Aron Burke, MD

Family Physician of the Year The Missouri Academy of Family Physicians (MAFP) presented Richard Aron Burke, MD, of Rock Port, Missouri, with the 2013 Family Physician of the Year Award at the Academy’s 65th Annual Scientific Assembly held June 7-8 in Lake Ozark, Missouri. Dr. Burke was chosen as the award recipient by a committee of family physicians from nominations made by patients, community members, and fellow physicians. Dr. Burke was chosen as the award recipient by a committee of family physicians from nominations made by patients, community members and fellow physicians. Dr. Burke grew up as the son of a local farmer who also worked for the locally owned utility company for over 30 years and a high school teacher and coach in Rock Port, Missouri. He attended Rock Port R-II High School and in 1998 graduated second in his class at the University of Missouri – Kansas

Pictured above: Dr. Burke mentoring Dr. Dustin Carpenter. Photo submitted by the Atchison County Mail, Rock Port, Mo.

City School of Medicine. After completing his residency at the University of Arkansas for Pictured above, left to right: Alex, Dr. Burke, Joanna, Journi, and Aidan (front). Medical Sciences, Fayetteville, Arkansas, he returned to his him advocating for change. This is true not home community and joined his mentor, only in terms of bettering the healthcare Dr. Wallace Carpenter, in practice. Shortly needs of our residents, but also in the many after his return, Dr. Carpenter retired and ways he helps to make our community a Dr. Burke continued his practice in Tarkio better place to live." and Rock Port and was appointed to the "We can always trust that he will Medical Staff at Community Hospital – be candid and honest. We are so very Fairfax in 2001 – both positions in which fortunate to have him in our little portion he continues serving today. He currently of the world." serves as the Medical Director of the local Dr. Burke resides in Rock Port with his nursing home, ambulance district, and wife, Joanna Burke, PNP, and their three county health agency. Not only does Dr. children, Journi, Alex, and Aidan. He has Burke mentor local high school students been a member of MAFP since 2001. Dr. into the medical field, he is also a preceptor Burk's wife Joanna stated, " My husband for medical students, physician assistants, doesn't practice family medicine -- he IS a and nurses.He has participated in medical family physician." mission work overseas and also volunteers as team physician for local schools. Hospital CEO, Myra Evans, says "Dr. Burke has made himself and his practice available as a "training ground" for medical students and other professionals. He is always willing to help educate hospital staff in how to provide quality care." Other comments submitted on behalf of Dr. Burke included: "As our family doctor, Dr. Burke has always provided us with excellent care. He has on numerous occasions tended to our health needs outside of normal business hours and has done this . . . because he takes pride in his role as our family physician and wants to ensure that his patients are being well cared for." Pictured above are patients Aaron "Dr. Burke demonstates commitment Schlueter and his new baby sister, to our community and when he sees a need Elizabeth with Dr. Burke. locally, it is likely that you will see or hear

14 Missouri Family Physician July - September 2013


Membership Anniversaries MAFP

Congratulations

to all of MAFP members celebrating a milestone anniversary in 2013. Thank you for your continued support of family medicine, your fellow physicians, and your patients.

•60 Years• Richard L. Bartley, MD (Springfield) •55 Years• Richard P. Bowles, MD, FAAFP (Kearney) William L. Fair, MD (Chillicothe) Marvin L. Fowler, MD (West Plains) Robert B. Young, MD, FAAFP (Williamsburg,VA) •50 Years• William R. Green, MD (St. Louis) William P. Hamilton, MD (Verona) Gene A. McFadden, MD, FAAFP (Waverly) •45 Years• Richard A. Brummett, MD, FAAFP (St. Louis) Billy G. Crayton, MD, FAAFP (Kansas City) Ireland W. Kimball, MD (Kansas City) John E. Murphy, MD, FAAFP (Pleasant Hill) •40 Years• Fred Caldwell, MD (Poplar Bluff) Jack M. Colwill, MD (Columbia) Willard E. Hawkins, MD, FAAFP (Springfield) •35 Years• Thomas W. Alderson, MD, FAAFP (St. Joseph) Edwin D. Breshears, MD, FAAFP (Fulton) R. Michael Collison, MD, FAAFP (Springfield) Walter E. Dean, MD, FAAFP (Lee’s Summit) Devera Elcock-Skimming, MD, FAAFP (Chesterfield) Polly C. Galbraith, MD (Kansas City) Max H. Goodwin, MD, FAAFP (Branson) Crisanto S. Gualberto, MD, FAAFP (Vandalia) Larry W. Halverson, MD, FAAFP (Springfield) Richard T. Honderick, DO, FAAFP (Springfield) Lonnie J. Kennington, MD, FAAFP (Chesterfield) Gene H. Leroux, MD, FAAFP (Doniphan) Peter R. Marcellus, MD, FAAFP (Branson) Douglas W. Ragland, MD, FAAFP (St. Joseph) Lawrence A. Rues, MD, FAAFP (Kansas City) Marvin P. Steiner, MD, FAAFP (Independence) F. L. Thompson, MD, FAAFP (Nevada) Terrance E. VanBuskirk, MD, FAAFP (Independence) Russell D. White, MD, FAAFP (Kansas City)

•30 Years• Anne M. Arey, MD, FAAFP (Lee’s Summit) David O. Barbe, MD, FAAFP (Mountain Grove) Jonathon M. Bird, MD, FAAFP (Farmington) Dennis N. Breed, DO, FAAFP (Kansas City) Robert N. Buffaloe, MD (Harrisburg) Rama D. Devabhaktuni, MD (Chesterfield) Henry F. Domke, MD (Jefferson City) William S. Donnell, MD (Bolivar) Sidney K. Griffith, MD (Cape Girardeau) Dennis E. Hughes, DO, FAAFP (Fayetteville,AR) Kim C. Ireland, MD, FAAFP (St. Louis) Timothy J. Little, MD (Kansas City) Rodney McFarland, MD, FAAFP (Neosho) Robert F. Morgan, MD, FAAFP (St. Louis) Michael L. O’Dell, MD, FAAFP (Kansas City) Michael S. Pennington, MD (Springfield) David V. Pulliam, DO, FAAFP (Higginsville) Richard O. Schamp, MD, FAAFP (St. Louis) Michael E. Shinn, MD, FAAFP (Kansas City) David K. Showers, DO, FAAFP (Springfield) Scott R. Soerries, MD, FAAFP (St. Louis) Kenton L. Stringer, MD (Republic) Ted C. Vargas, MD (Pacific) James J. Weiss, MD (Jefferson City) Michael C. Wulfers, MD, FAAFP (Cape Girardeau) •25 Years• David H. Afshar, DO (Branson) Sara A. Bohn, DO, CMD, FAAFP (California) Gregory W. Boyd, DO (Lee’s Summit) Kenneth S. Braton, DO (Grandview) Cynthia D. Croy, MD (Joplin) Thomas E. Dahlberg, MD (Springfield) Thomas E. Davis, MD, FAAFP (New Haven) Todd E. Fristo, MD (Lee’s Summit) James W. Hall, MD (Kansas City) Diane M. Harper, MD, FAAFP (Leawood, KS) Robert W. Heath, MD, FAAFP (Springfield) Grant S. Hoekzema, MD, FAAFP (Creve Coeur) Thomas A. Hopkins, MD (Lamar) Rosa A. Kincaid, MD, FAAFP (St. Louis) Thomas F. Landholt, MD (Springfield) Robert E. Mason, DO, FAAFP (Lake Ozark) Linda S. Myers, MD (Joplin)

•25 Years• Stephen J. Nester, MD (St. Louis) John Peterson, DO, FAAFP (Blue Springs) Daniel C. Roney, MD (Kansas City) Debra L. Royce, MD (Sarcoxie) Paul Schoephoerster, MD (Fayette) Jeffrey A. Scott, MD (Grandview) Douglas D. Smith, MD, FAAFP (Odessa) George D. Solomon, MD (Columbia) Deborah D. Stoner, MD (Hiawatha, KS) John C. Tabb, DO (Lebanon) Ronald L. Vance, MD, FAAFP (Bolivar) Julie K. Wood, MD, FAAFP (Lee’s Summit) Elizabeth A. Wuebbels-Jones, MD (High Ridge) Rose J. Zwerenz, MD, FAAFP (Kansas City)

Pictured above: Robert Mason, DO, and friend Rhae Duncan, celebrate his 25 years of membership with MAFP at the Annual Scientific Assembly in June. Pictured (inset): Dr. Mason accepts his membership anniversary award from Kate Lichtenberg, DO, MAFP Board Chair, at the awards and installation dinner.

Join us!

MAFP 66th Annual Scientific Assembly

June 6-7, 2014 Lodge of Four Seasons Lake Ozark, Missouri

Missouri Family Physician July - September 2013

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MAFP Welcome Dr. Fish

Meet New 2013-2014 MAFP President William Fish, MD, FAAFP William W. Fish, MD, FAAFP, of Liberty, Missouri, was installed as the 65th President of the Missouri Academy of Family Physicians (MAFP) during the Annual Meeting in Lake Ozark, Missouri, on June 8, 2013. Serving as President last year, Kate Lichtenberg, DO, MPH, FAAFP, Kirkwood, Missouri, subsequently became Board Chair. Other officers include President-elect Daniel Purdom, MD, FAAFP, of Liberty; Vice President Peter Koopman, MD, of Columbia; and Secretary-Treasurer Tracy Godfrey, MD, of Joplin. Dr. Fish attended medical school at University of Missouri – Kansas City School of Medicine and completed his residency at Baptist Medical Center. Dr. Fish was one of the founders of The Liberty Clinic in 1984 where he continues to practice. He is board certified by the American Board of Family Medicine. He resides in Liberty with his wife, Mary Beth. They have three children. Dr. Fish has been a member of the MAFP since 1984 and served as MAFP Advocacy Commission Chair from 2008-2011. Pictured above are Arthur Freeland, MD, William Fish, MD, and Mary Beth Fish. Following the Installation, Dr. Fish thanked previous leaders, staff, his own family physician, his parents, family and his wife. Dr. Fish's remarks were humorous and really hit home with his colleagues. He touched on his day-to-day experiences as a family physician of 32 years and the optimistic future of family medicine. Dr. Fish also commented on MAFP's recent awards from AAFP.

educational support with loan repayment assistance, and decrease the administrative burden on our profession. We’ll continue to support our national organization in eliminating the skewed system of determining relative value of work and work to disband the RUC or re-balance it to provide more primary care representation. I’m looking forward to the Special guests and family members who joined in celebrating Dr. Fish's installation are pictured next few years, the above, left to right: Gary Martin, friend, Amy Bunte, niece, Dr. Fish, Mary Beth Fish, Linda Martin, challenges we face, Jordan Bunte, great-niece, and Kailee Bunte, great-niece (front). Dr. Fish addressed and the potential the gathering, for benefits to "As with many things in life, attitude is time to sit on the sidelines and watch. our profession and the health care of everything. We can become disenchanted Our state academy is fortunate to have a Missourians. Until we achieve all of our and regretful or we can appreciate how supportive and active membership. We goals, I hope you will always look at the good we have it and work diligently to also have great support from the youth of glass as half full rather than half empty. improve things so they can be even better. Family Medicine in Missouri. This occurs I am certainly thankful for being able to This is what your Missouri Academy because we have an engaged membership. earn a living doing what I love to do and works to achieve. We want things in I plan to have many more positive and our state to result in the latter type of While we have had many successes on the optimistic conversations with many of conversation and not the former. It takes legislative front, we still need to achieve you in the future." an effort from everyone and it isn’t a meaningful tort reform, family medicine 16 Missouri Family Physician July - September 2013


2013 Annual Scientific Assembly Photos MAFP

Merry Mary, caricature artist, is pictured Chase Granberg, son of Bryce and Dana with Kailee Bunte, great-niece of Bill Fish, Granberg, MD, poses with his dragonMD, at the family picnic on Friday evening. painted face at the family picnic.

Kate Lichtenberg, DO, MAFP Board Chair, is pictured with Brendan Bagley, MD, who received his Degree of Fellow certificate at the Awards Dinner on Saturday evening.

Todd Shaffer, MD (left) presents Arthur Freeland, MD (right) with the Soaring Eagle Advocacy Award at the Awards Dinner.

Medical students pictured above, L to R: Emily Kahn (UMKC), Kevin Gray (UMKC), and David Kramer (KCUMB) at the Friday evening family picnic.

Mimi Propst, MD, is pictured above with husband Austin Propst and daughter Brooklyn at the Saturday evening social mixer.

Julie Busch, MD, and husband Bryan Swearngin with Aliya and Owen Swearngin are pictured above at the Saturday evening social mixer.

Lodge of Four Seasons Executive Chef H. Joseph Elliott and his Sous Chef presented a food demonstration to family members of conference participants on Friday afternoon.

Mia Bagley (left) and sister Lauren (right), daughters of Mary Ann and Brendan Bagley, MD, are pictured above displaying their face paintings at the family picnic.

Jackie Newton aka Sparkie Da' Clown is pictured above with Bill Fish, MD (left) and Arthur Freeland, MD (right) at the Friday evening family picnic.

Denise Buck, MD (right) is pictured above with her aunt Jane Zimmer Daniels, PhD at the Friday family picnic.

Pictured above L to R: David Kramer (KCUMB student), Jenny Eichhorn (UMKC student), Laurie Bernskoetter (MAFP Staff), George Harris, MD, and Amanda Williams (UMKC student) attending the Saturday evening social mixer.

Richelle Koopman, MD and Peter Amber Granberg, daughter of Bryce and Koopman, MD are pictured above with Dana Granberg, MD, poses with her daughters Katie (left) and Liz (right) at the caricature print at the family picnic. family picnic.

See page 27 for Resident Poster Contest Winners

Missouri Family Physician July - September 2013

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MAFP FMCC

Family Medicine Congressional Conference

The Family Medicine Congressional Conference (FMCC), held May 14-15, is an exceptional opportunity to understand federal advoccy, get up-todate on current priorities for family medicine, receive practical, hands-on experience with the legislative process, and share the power of personal in Washington, DC -- all in two days. Save the date! FMCC 2014 April 7-8. Visit www.aafp.org/events/fmcc.html for more information. MAFP had three residents showing extreme interest in advocacy and they are sharing part of their stories. FMCC focused on federal funding needed for America's Primary Care Workforce, Modernizing Primary care GME, medical liability reform, physician collective negotiation, physician payment reform and the value of primary care, and reauthorize Teaching Health Center (THC) programs. Aaron Whiting, MD Resident - UMC FMR "A diversity of ideas were represented at FMCC, as with any large group of people, but the focus was placed on using our common values as a launching point for addressing the issues." Primary care physician in the role of citizen advocate was of chief importance at FMCC. The conference was highlighted by inspirational speeches from Representative Ami-Bera, MD (D-CA), Representative Bill Cassidy, MD (R-LA) and Representative Joe Heck, DO (R-NV). All were physicians who had risen to the role of public official, and modeled the impact an involved physician can make. Not everyone has to be a senator or representative to make a difference however. Physicians hold a unique role as natural leaders in their communities, and the rising recognition in Washington that primary care will play a central role in solving the healthcare crisis has our leaders listening. “Call your congressman, write a letter, send an email” have become cliché calls to action, but it really is that simple. We practiced our pitches, and on the second day of the conference with nothing more than a phone call and an appointment, we took to Capitol Hill. Our delegates of Missouri family physicians and students met with congressional leaders, or their staff, equipped with knowledge on the issues. With concise and direct interactions, we conveyed our positions to a surprisingly receptive bipartisan audience. FMCC was a great opportunity to meet fellow physicians, make new friends, and

just have a great time in our capitol. If you are interested in public policy, or even if you are not but recognize its necessity, the FMCC is a great introduction to advocacy ■ Brandon Luk, MD Resident - SLU FMR "I came to learn and advocacy is found not in the clauses or conditions of the legislative bills but in intimate storytelling in the often cramped and crowded offices of staff and representatives." Up until this year, I never paid attention to politics. Washington DC was almost Hollywood to me - a world immersed in drama and storylines that seemed like it could only exist on the big screen. Outside of voting and paying my taxes, the political world was distant and I was indifferent; having the narrow focus of medical science, I’ve not seen the effects of policy, with the exception of hospital policies. It was not until I began to navigate this great maze of primary care medicine, that I realized caring for sick and healthy patients is not as simple as point A to point B. Instead, the preconditions, requirements, environment of, and barriers to reaching point B were not set forth by a patient and their healthcare provider. It was set forth by national policy found within the marble floors of the Senate, the walls of Congress, and its effects are found in the congested waiting rooms of emergency rooms, inability for healthy patients to access preventative care, lack of incentives or funding to draw debt ridden students into primary care fields, or the medical

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clinics serving thousands of patients that find themselves in financial distress due to an imbalanced system of reimbursement. The FamMedPAC, led by Dr. Wexler and Mark Cribben, JD, made it clear that it was the only political action committee that actively advocated for family medicine. The lecture addressed the efforts of the PAC, and the importance of donating to help fund the daily efforts of providing family medicine with a voice at the congressional table. I donated. (And for residents and students reading this, it was significantly discounted for us as a “Club George” member). By the end of the day, while exhausted, I left with a renewed sense of what medicine is all about - that ultimately being a patient advocate was not only treating the sick and maintaining the healthy, it was also speaking for them in the world that has the most impact on them, yet sometimes the furthest removed. As my departing flight left and I saw the nation’s capital fade from sight, I couldn’t help but imagine that in seeking point A to point B of caring for patients, Washington DC is someday to become my point C ■

MAFP PAC Join Club Jefferson Simply pledge $2 per week, $104 per year and you can help us shape the future of patient care and family medicine in Missouri. Our goal is to involve as many members as possible. We begin by seeking that one voice in one hundred – yours! Donate online at www.mo-afp.org/political.htm


FMCC MAFP Drew Glover, MD Resident - UMKC FMR "I feel the future of family medicine is strong. Now what is left to do but get involved? It is imperative that as a group, we begin the work of change, locally and nationally. Call your representatives, follow them on twitter and facebook, write them, email them and make our positions known. Let them know we are unified, we are passionate and we are ready for the challenge! Toward the end of day one there was a particularly interesting presentation on the need for dedicated evaluation and management codes for family medicine. The presentation focused on the fact that using the same E/M codes for PCPs and specialists doesn’t add up as specialists' revenue is typically made up of about 17% of E/M codes while PCPs revenue is averaging about 55%. This is a substantial discrepancy that has long been the culprit in the devaluation of family medicine. While many alternative methods for calculating reimbursement have been

proposed, one method discussed in detail at the conference was the Katerndahl Complexity/Density model in which calculated not only the complexity of the patient and the breadth of possibilities within a specialty, but also the complexity and density per unit of time. Using this particular model, the value of the PCP was much greater and, in fact, more valuable than that of a non-interventional cardiologist. An interesting method and one I believe and hope we will be hearing about again. Day two came and the anticipation grew. This was the day we set our sights on the Hill. We traveled Pictured left to right: Kevin Helm, Executive Director of AFMRD, in our pack of Missouri Todd Shaffer, MD, Peter Koopman, MD, Aaron Meyer (SLU constituents: physicians, Student), Drew Glover, MD (UMKC FMR), Bradley Harr (KCUMB residents, medical students, Student), Aaron Whiting, MD (MU FMR), Jennifer Bauer, MAFP and administrative leaders. Executive Director, and Brandon Luk, MD (SLU FMR). We met with representatives and discussed our asks. We and addressing the shortage of physicians asked for support to repeal the SGR, caring for the underserved. We asked to to appropriate $71 million for Title VII reauthorize the Teaching Health Center 747 primary care grants, to provide $305 program and most importantly, we told our million for the National Health Service stories, well, more truthfully, our patient’s Corps as authorized by the ACA in order stories ■ to aid in scholarships, loan repayment

What is the MAFP PAC? MAFP PAC is the state political action committee of the Missouri Academy of Family Physicians. MAFP PAC is a special organization set up to collect contributions from a large number of people, pool those funds and make contributions to state election campaigns. Where does my contribution go? MAFP PAC will make direct contributions to candidates for the Missouri General Assembly (either State House of Representatives or State Senate) and statewide offices. Contribution decisions are made in a nonpartisan way based on candidates' positions, policies and voting records as they relate to family physicians and our patients. Direct contribution decisions are made by the PAC Committee. I already pay my dues - isn't that enough? Election laws prohibit the use of membership dues for donations to political candidates. Funds to be used for donations to candidates must be raised separately from membership dues. Voluntary MAFP PAC donations are what will enhance MAFP's clout in the elections and with elected members of the Legislature.

Thank you to all PAC Contributors at the Club Jefferson Level William Fish, MD Dana Granberg, MD George Harris, MD, MS David Kapp, MD Peter Koopman, MD Kate Lichtenberg, DO, MPH Lisa Mayes, DO Darryl Nelson, MD John Paulson, DO, PhD

Perryville Family Care Clinic Jonathan Privett, MD Lawrence Rues, MD Mark Schabbing, MD Robert Shaw, MD James Stevermer, MD Jeff Suzewits, DO, MPH Jamie Ulbrich, MD

Get Involved! Make your 2013 contribution online at www.mo-afp.org Missouri Family Physician July - September 2013

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MAFP 2013 Legislative Session Update

Health Care Legislation - 2013 Session of the Missouri General Assembly by Pat Strader, MAFP Governmental Consultant The 2013 legislative session ended on Friday, May 17. There were major issues left in limbo when the clock ran out. Health related issues included addressing Medicaid expansion/transformation and tort reform repair. Other issues left unresolved included a proposed 10-year, 1 cent statewide sales tax for transportation, bonding for schools, and tax credit reform. The Legislature did pass several major pieces of legislation relating to taxes, workers’ compensation/second injury fund, and unemployment compensation. Governor Nixon expressed concerns about the tax measure which would cut business taxes in half over a five-year period and phase in a smaller reduction in the state’s income tax, all totaling about $800 million a year. Governor vetoed the unemployment compensation and tax cut bills. Following is an overview of the key 2013 legislative issues of interest to MAFP – those that passed and those that failed to pass. The Governor has until July 14 to sign or veto bills. Legislation becomes effective on August 28, 2013, unless the bill has a specific effective date or contains an “emergency clause.” State Budget – The almost $25 billion budget made it to the Governor’s desk in ample time. One item of contention was the amount of dollars set aside by the Legislature for building repairs of the State Capitol and new facilities - Fulton State Hospital and a state office building at the old Missouri State Penitentiary site in Jefferson City. The Governor’s budget focused on money for Capitol repair, a new Fulton State Hospital, and improvements at state parks, but did not include the potential new state office building. During the appropriations process and during budget debate on both the House and Senate floors, attempts were made by a

number of legislators to include necessary language to allow Missouri to access the federal dollars for Medicaid expansion, but all of those efforts failed. Tort Reform (HB 112; SB 105) Legislation to create a statutory cause of action and restore the caps on noneconomic damages in medical malpractice cases failed to pass. SB 105 sponsored by Senator Dan Brown was never taken up for a vote in the Senate Judiciary Committee. HB 112 (Burlison) made it through the House with a 93-62 vote. When HB 112 made it to the Senate, it was quickly referred and voted out of the Senate Small Business, Insurance and Industry Committee. It was first debated on the Senate floor for eight hours, but laid over when a filibuster ensued. Efforts by key legislators to broker a compromise also failed near the end of session. A number of other bills were filed that would have created a “constitutional amendment” allowing the legislature to act on caps. While most of those were heard in committee they did not progress further. Medicaid Transformation/Expansion Many bills were filed and numerous hearings were held, but the Republicanled legislature was opposed to expansion, saying the system is broken and needs transforming. About all that ended up passing was HB 986 by Representative Jay Barnes (R-Jefferson City) – a mere piece of his original HB 700 which would have put most all Medicaid recipients into managed care, and moved other groups to buy insurance through the future health insurance exchange. HB 986 provides that the President Pro Tem of the Senate and the Speaker of the House may jointly establish a “Joint Committee on Medicaid Transformation.” If established the Committee would be composed of 12 members – 6 Senators and 6 State Representatives. The provisions of this

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section expire January 1, 2014 which means if a committee is formed and a report and recommendations are finalized, it must all be accomplished by the end of the year. The committee would be charged to study a number of things including development of methods to prevent fraud and abuse in the MO HealthNet system; study and advise on the best manner in which to provide incentives, including a shared risk and savings to health plans and providers to encourage cost-effective delivery of care; and study ways that individuals who currently receive medical care coverage through the MO HealthNet program can transition to obtaining their health coverage through the private sector. NOTE: See updated activity on appointment of Medicaid Interim Committees at the end of this report. LEGISLATION THAT PASSED Physician Assistant Scope of Practice This legislation revises the definition of “physician assistant supervision agreement” and repeals the burdensome physician-PA waiver process. It repeals the requirement that a PA work in the same facility as the supervising physician 66% of the time the PA provides care but provides that the PA only practice where the supervising physician routinely provides patient care, except existing patients of the supervising physician in the patient’s home and correctional facilities. The supervising physician must be immediately available in person or via telecommunication during the time the PA is providing patient care. Prior to commencing practice, the supervising physician and physician assistant shall attest on a form provided by the board that the physician shall provide supervision appropriate to the physician assistant's training and that the physician assistant shall not practice beyond the physician assistant's training and experience. Appropriate

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2013 Legislative Session Update MAFP

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supervision shall require the supervising physician to be working within the same facility as the physician assistant for at least four hours within one calendar day for every fourteen days on which the physician assistant provides patient care. Only days in which the physician assistant provides patient care (as described in the bill) shall be counted toward the 14-day period. The requirement of appropriate supervision shall be applied so that no more than 13 calendar days in which a PA provides patient care shall pass between the physician's four hours working within the same facility. (In HB 315) Signed by the Governor Nurses • Nurses/Telehealth – Requires by January 1, 2014, BOHA and the Board of Nursing establish the “Utilization of Telehealth by Nurses.” An APRN who provides nursing services within a collaborative practice agreement is permitted to provide the services outside the geographic proximity requirements if the collaborating physician and the nurse utilize telehealth in the care of the patient and if the services are provided in a rural area located in a health professional shortage area in Missouri. All telehealth providers are required to obtain patient consent before telehealth services are initiated and ensure confidentiality of medical information. (HB 315; Original bill was HB 936) HB 315 Signed by the Governor • Rural Health Clinics – Allows for the waiver of the proximity requirement for no more than 28 days per year in order for APRNs to provide care to independent RHCs and RHCs that are critical access hospital-based. (SB 330) Signed by the Governor • Allows Board of Nursing to request an “emergency suspension” of a nursing license (HB 315) Signed by the Governor Any Willing Provider in Exclusive InNetwork Plans – Under this act, HMOs and other health carriers may offer health benefit plans that are managed care plans

that require all health care services to be delivered by participating providers in the HMO’s or health carrier’s network. The language was amended so that the carrier shall offer at least one additional health benefit plan option that includes an outof-network benefit. To participate, the any willing licensed physician must agree to accept 85% of the health carrier’s standard prevailing or market fee schedule, payment or reimbursement rate for such network in the specific geography of the licensed physician’s practice. This provision shall not apply to any licensed physician who does not meet the health carrier’s selection standards and credentialing criteria or who has not entered into the health carrier’s standard participating provider agreement. (SB 262) Signed by the Governor Community Paramedics – Allows a person to be eligible for certification by DHSS as a community paramedic if he or she is currently certified as a paramedic; successfully completes or has successfully completed a community paramedic certification program from a college, university, or education institution that has been approved by the department or accredited by a national accreditation organization approved by the department and completes an application form. A community paramedic must practice in accordance with protocols and supervisory standards established by the medical director and must provide the services of a health care plan if the plan has been developed by the patient’s physician, APRN or PA and the patient isn’t receiving services from another provider. An ambulance service must enter into a written contract to provide community paramedic services in another ambulance service area. (HB 336, HB 307) Both bills signed by the Governor Telemedicine – Requires insurance companies to reimburse telehealth services at the same rate as services delivered in person. Prohibits insurers from denying coverage for telehealth services (SB 262) Signed by the Governor Credentialing of Health Care Practitioners – Requires health carriers to

credential a health care practitioner within 60 business days of receiving a completed application and to pay the practitioner for treatment services pending approval. (SB 262) Signed by the Governor Physical Therapy Co-pays – Prohibits health carriers from imposing greater copayments or coinsurance percentages to insureds for prescribed covered services provided by a licensed PT than those charged for the same covered services provided by licensed primary care physicians. Under the act, health carriers must clearly state the availability of PT coverage under its plan and all related limitations, conditions, and exclusions. An amendment was added late in the process requiring the Joint Committee on Legislative Research to perform an actuarial analysis of the cost impact of the mandate. (SB 159) Signed by the Governor Pharmacy Emergency Dispensing – Allows pharmacists to dispense 7-day emergency prescriptions if the prescribing physician is incapacitated or deceased. This does not include dispensing of controlled substances. In the event of prescriber death or incapacity or inability of the prescriber to provide medical services, the amount dispensed shall not exceed a thirty-day supply. The pharmacist must record such dispensing and notify the patient’s physician. (HB 315) Signed by the Governor Eating Disorders/Orally Administered Anticancer Medications – The Joint Committee on Legislative Research must conduct an actuarial analysis of the cost impact to consumers, health insurers, and other private and public payers if a state mandate was enacted to provide health benefit plan coverages for (1) Orally administered anticancer medications charged at the same out-of-pocket cost as intravenously administered or injected cancer medications; and (2) Diagnosis and treatment of certain eating disorders that include residential treatment and access to psychiatric and medical treatments. Under this act, the director must submit by December 31, 2013, a report of the actuarial findings to the Speaker of the

continued on page 22

Missouri Family Physician July - September 2013

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MAFP 2013 Legislative Session Update

Legislative Update continued from page 21 House, Senate President Pro Tem, Chair of the House Special Committee on Health Insurance and Chair of the Senate Small Business, Insurance and Industry Committee. (SB 161) Signed by the Governor Volunteer Health Services – Establishes the Volunteer Health Services Act which allows a licensed health care provider to provide volunteer professional health care services for a sponsoring organization. Any person with a suspended or revoked license or who provides services outside the scope of his or her license is not eligible to provide services under the act. Before a health care professional can provide volunteer services, the sponsoring organization shall register with the Department of Health and Senior Services and pay a $50 fee. A sponsoring organization must file a quarterly voluntary services report with the department, keep its records of health care provider volunteers up to date, and maintain the records for five years following the service rendered by the health care provider volunteer. Any health care provider volunteering his or her services shall not be liable for any civil damages for any act or omission resulting from his or her service unless there was gross deviation from the ordinary standard of care or willful misconduct. "Gross deviation" is defined as the conscious disregard for the safety of others. (SB 129) Vetoed by the Governor Medical Records – Modifies current law so that the fees are more equalized whether the records are provided on paper or in electronic format and adjusts the maximum fee for providing records in electronic format from $25 to $100. (HB 351) Signed by the Governor Pulse Oximetry Screening – Establishes “Chloe’s Law” by adding pulse oximetry screening to the list of required newborn screenings. The statute includes certain reporting requirements to DHSS for births, including home births. (SB 230) Signed by the Governor

Individual and Group Policy Form Approval Process – This measure modifies the process for approving group and individual health insurance policy forms. If a policy form is disapproved by the Director, all specific reasons for nonconformance shall be stated in writing within 45 days from the date of the filing. (SB 262) Signed by the Governor Utilization Review Procedure – This act updates Missouri’s current utilization review procedure so that health carriers may notify health care providers of certain insurance determinations in an electronic manner. Current law only allows health carriers to notify providers by telephone. (SB 262) Signed by the Governor Licensure of Navigators – Provides that no individual or entity shall perform, offer to perform, or advertise any service as a navigator in Missouri or receive navigator funding from Missouri or a health insurance exchange unless licensed as a navigator by the Department of Insurance, Financial Institutions and Professional Registration. (SB 262) Signed by the Governor Medical Records/Guns – Changes the laws regarding firearms and establishes the “Second Amendment Preservation Act.” Under the act, a licensed health care professional cannot be required by law to inquire if a patient owns a firearm, document or maintain in a patient’s medical records if the patient owns a firearm, nor notify any governmental entity of the identity of a patient based solely on his or her status as a firearm owner. These provisions cannot be construed as prohibiting or restricting a health care professional from requesting or documenting the information if it is necessitated or medically indicated by the professional’s scope of practice and it does not violate any other state or federal law. (HB 436) Vetoed by the Governor Prescription Eye Drop Refills – Requires a health carrier that offers or issues plans on or after January 1, 2014, that provide coverage for prescription eye drops to provide coverage for refilling the eye drop prescription prior to the last day of the

22 Missouri Family Physician July - September 2013

insured’s dosage period as long as the prescribing health care provider authorizes the early refill and the health carrier or benefit plan is notified. (HB 315) Signed by the Governor Meningococcal Disease Brochure for Higher Education – Requires DHSS to develop and make available on their website an informational brochure relating to meningococcal disease. DHSS must notify each public institution of higher education of the brochure’s availability and the institutions must provide a copy of the brochure to all students and to parents if the student is less than 18 years of age. (SB 197) Signed by the Governor Tuberculosis Treatment and Prevention Modifies current provisions relating to TB treatment, prevention and commitment by granting more authority to DHSS and local public health authorities. Current law requires a person found to have TB to obtain the required treatment, minimize the risk of infection and allow for a TB patient to be committed under certain circumstances. This act specifies that local public health authorities may institute proceedings to petition for directly observed therapy or commitment of the person with TB. (SB 197) Signed by the Governor MAJOR LEGISLATION OF INTEREST TO MAFP THAT FAILED TO PASS Nurse Independent Practice – Would have expanded the scope of practice for APRNs and ended the current requirement for working in a collaborative practice arrangement with a physician. Would also have created a new licensing category for APRN’s and severely clouded how they would work within their training in a certain specialty. (HB 315; SB 167) Clinical Laboratory Science Practice Act This act would have required licensure for laboratory technicians and phlebotomists and affected point-of-care testing for family physician offices (SB 362; HB 922) Prescription Drug Monitoring Program – Would have

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2013 Legislative Session Update MAFP

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established a PDMP for Missouri. (SB 233)

Midwives • Would have required lay or certified midwives to carry $1 million in liability insurance (HB 308) • Would have set up a licensing process and established a Board of Professional Midwives within the Division of Professional Registration (HB 514) Motorcycle Helmet Repeal – Various bills filed and amendments offered to moving bills that would have repealed Missouri’s helmet law. With lots of work on the last few days of session, we were able to get the amendment removed from several omnibus transportation bills (HB 555) Missouri Clean Indoor Act – Would have established new laws regarding smoking in public places (HB 523) Vaccinations/Immunizations/ Administration of Vaccines • Would have required every child 11 years of age to receive one dose of meningococcal conjugate vaccine and one booster dose after the child reaches 16 years of age (HB 705); • Would have established “Molly’s Law” that requires a health care practitioner to provide the list of ingredients in a vaccination to the parent or guardian of children prior to the administration of the vaccination (HB 317); • Would have allowed pharmacists to administer all vaccines after appropriate training on the contraindications and adverse reactions to each vaccine (HB 454) Medical Records/Guns – Would have prevented health care professionals from asking about or entering information about firearm ownership into medical records and school employees from asking students about guns in the home (HB 639; SB 266) Meth Elimination Act/Pseudoephedrine Purchases – Would have reclassified some

forms of methamphetamine precursor drugs from Schedule IV and V controlled substances to Schedule III requiring a prescription. (HB 991)

absorbed, dissolved, or ingested) and vapor products (E-cigarettes) to be subject to the same provisions as tobacco products. (HB 751)

Medicaid Fraud – Would have established the Missouri False Claims and Fraud Prevention Act and allow a person to file a suit in the name of himself, herself or the state. (HB 839)

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Chiropractors Reimbursement/MO HealthNet – Would have required MO HealthNet reimbursement for chiropractic services (HB 598) Tanning Devices – Would have required parental consent before using a tanning bed. (HB 47) Texting While Driving – Various bills were filed that would have prohibited texting while driving. (HB 145, HB 394, HB 524, HB 694) Tobacco Use in Private Businesses – Would have specified that if any political subdivision prohibits use of tobacco in a private business under Section 191.722, RSMo, all tax revenue generated by the business through property taxes and county sales taxes must be remitted to the local school district in lieu of the political subdivision. (HB 1021)

Interim Medicaid Committees Appointed At publication, we have added activity that has occurred regarding appointment of Interim Committees to Study Medicaid Transformation this summer and fall as follows: • Senate Interim Committee on Transformation and Reform (chaired by Senator Gary Romine) • House Interim Committee on Medicaid Transformation (chaired by Rep. Jay Barnes) • Citizens and Legislators Working Group on Eligibility and Reform (chaired by Rep. Noel Torpey). This working group will meet and travel throughout the summer to hear informational testimony during public meetings and create a report to be given to Rep. Barnes’ legislative committee.

Tobacco-Derived and Vapor Products – Would have required tobacco-derived products (noncombustible product derived from tobacco that is intended for human consumption whether chewed, Missouri Family Physician July - September 2013

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MAFP Resident Grand Rounds

Presentation of a schwannoma as a painful soft tissue lesion in the lower extremity of a 13 year old girl

Mark Mueller, MD

Aaron Gray, MD

Mark Mueller, MD, University of Missouri - Columbia, Dept. of Family and Community Medicine Aaron Gray, MD, University of Missouri - Columbia, Dept. of Family and Community Medicine & Dept. of Orthopaedic Surgery Kyle Fiala, DPM, University of Missouri - Columbia, Dept. of Orthopaedic Surgery Introduction Soft tissue masses of the lower extremity are a rare but important condition to diagnose correctly. While previous assessments have shown that approximately 90% of these lesions are benign in nature, a malignant process must always be considered.1 Asymptomatic extremity lesions may be identified during routine examinations or patients may present due to an enlarging mass causing discomfort and neurological symptoms. A general workup of this condition begins with a thorough medical history, including the length of time the lesion and associated symptoms have been present, growth patterns, and screening for potential systemic conditions that may be associated (e.g. rheumatoid arthritis, gout, neurofibromatosis). Exam includes a thorough evaluation of the lesion including palpation and identification of location, consistency and possible neural involvement. Adjunct imaging (MRI is most useful) and potential biopsy can help in final diagnosis and management can vary from observation to immediate excision based on symptoms and severity of diagnosis. Case A 13-year-old female originally presented to a family medicine practitioner in orthopedic clinic with a general complaint of a painful, swollen mass involving the third toe on her right foot. She stated that the mass had been present after stubbing this toe five years prior. She also stated that it had grown in size and the pain had greatly increased following an incident in August 2011 in which a family-owned cow stepped on the same foot. Since

then, she had persistent pain without any additional symptoms, specifically denying numbness or decreased range of motion. Her past medical and surgical history was unremarkable and she was not taking any medications. Upon exam, she was noted to have a swollen 3rd toe on the right foot. In particular, a nodular/cystic lesion, approximately 1cm in width and 3cm in length, was noted on the dorsal aspect of the toe, proximal to the metatarsal phalangeal joint, with overlying skin well adhered (Figure 1, 2). With mild palpation, the lesion was extremely tender and the patient complained of a burning, sharp pain in her toe and dorsum of foot. The patient had full range of motion of the joints in her toes and did not demonstrate pain or difficulty standing or ambulating. She was able to dorsiflex and plantar flex her toes and she was noted to have uncompromised circulation in the foot. There was no numbness or tingling noted in any area of the foot or toes. A three view series of foot x-rays demonstrated there were no fractures, dislocations and that the bones were normal consistency. A soft-tissue lesion was noted without calcifications. A follow up MRI showed a well-circumscribed, homogeneous, enhancing soft tissue mass in the dorsal subcutaneous tissue, spanning the distal metatarsal and the proximal phalanx. The lesion was not invading into deeper tissues. She was scheduled for surgical excision of the mass due to its changing characteristics and painful symptoms. A firm nodule was located dorsal to the extensor tendon

24 Missouri Family Physician April - June 2013

sheath and was removed with well-defined, clear margins. The specimen was sent for pathologic identification; wand histology confirmed the diagnosis of schwannoma. Discussion Lower extremity soft tissue lesions can arise from multiple tissues including bone, nerve, subcutaneous connective tissue, vascular tissue, muscle and tendon. Overwhelmingly, these lesions are benign in nature but it is crucial that malignancies be considered and ruled out. In general, tumors tend to be fixed, while cysts and lipomas are usually compressible. Soft tissue lesions of the lower extremity fall into the following three categories, in decreasing order of occurrence: 1) pseudotumoral lesions, 2) benign tumors, and 3) malignant tumors. Common diagnoses within these categories are further discussed below: 1) Pseudotumoral Synovial/Ganglion Cysts Together, these two slightly different conditions comprise the most common type of soft tissue lesions. Although typically found in the hand or wrist, on the lower extremity, they are commonly found on the dorsum of the foot or the anterolateral aspect of the ankle. Synovial cysts are usually found in the context of joint disease and represent a continuation or herniation of the synovium through a joint capsule.2 They are always in communication with the adjacent joint and have true synovial cells that line the fluid filled cyst. In contrast, ganglion cysts contain both synovial and mucinous fluid, have cyst walls

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that are lined with discontinuous pseudo-synovial cells, and do not always communicate with a joint.

pain or a “Mulder click” as the neuroma moves. MRI imaging may help confirm clinical diagnosis.

The most common appearance of both lesions is a firm, usually nontender, lesion. When symptomatic, they present with pain and sometimes limited joint mobility and nerve entrapment. Clinical differentiation can be difficult and diagnosis may be supplemented with ultrasound and MR imaging, the latter being preferred to identify the cystic nature of the lesion, connection with adjacent joints, and possible involvement of surrounding tissues or tendon sheaths. Treatment may consist of glucocorticoid instillation or possible excision for persistent symptoms.

Treatment usually begins with wearing shoes which have wide metatarsal support, with glucocorticoid injections and possibly neurolysis surgery if symptoms are not relieved.

Morton’s Neuroma This is a misnomer in that this lesion is not a true neuroma. It is considered to be the result of repetitive nerve compression and irritation, causing nerve degeneration, a poorly reorganized mass of axons, and perineural fibrosis.2 Therefore it is more accurately described as a fibroma. This lesion most commonly occurs between the 3rd and 4th metatarsal spaces, is more frequent in middle age and in females, and can be associated with wearing shoes with a narrow toe box, including high heels. Patients will often present with intermittent and burning pain in the area of the metatarsal head, worsened by movement and relieved by rest, massage, and shoe removal. Physical findings on exam are often negative, although squeezing the metatarsals together may elicit neuropathic

Figure 1

2) Benign Tumorous Lesions Neurofibroma These lesions are often thought of in the context of wider genetic conditions such as NF-1 and NF-2 but the majority are solitary nodules (90%). These are benign tumors of the nerve sheath and are comprised of a mixture of Schwann cells, perineurallike cells and fibroblasts. They present as a mass lesion causing local or radicular pain with possible sensorimotor symptoms. The local nerve will enter and exit the tumor with nerve fibers mixing with tumor components throughout. They can be cutaneous or involve deeper tissues and affect nerve roots and peripheral nerves. If asymptomatic and solitary, a neurofibroma may be observed. If multiple, the need to rule out a genetic condition exists. Schwannoma (neurilemmoma) In contrast to a neurofibroma, these encapsulated tumors are made entirely of Schwann cells, which come in two forms, myelinating and non-myelinating, Figure 2

and serve as the principal support cells to neurons of the peripheral nervous system. Schwannomas are the most common tumor of peripheral nerves, and combined with neurofibromas, represent approximately 10% of all benign soft tissue tumors.3 They can affect any age patient (peak ages 20 to 50 years), and are often solitary and sporadic. Local nerve fibers are incorporated into the tumor capsule and not intermixed with tumor cells throughout. Most schwannomas are asymptomatic but can cause abnormal sensation with palpation, radicular pain, sensory loss and local weakness. As with other lesions, these can be observed if asymptomatic but are often surgically excised. Lipoma Lipomas are indolent tumors consisting of mature adipose tissue. They are benign in nature and occur between the skin and the muscles. In general, they are asymptomatic, may enlarge slowly over time and are soft, mobile, and nontender upon examination. If superficial, they will often appear well circumscribed. They can be excised if they grow to a size to compress other tissues or cause localized pain. Pigmented Villonodular Synovitis (PVNS)/ Tenosynovial Giant Cell Tumor (TGCT) These conditions are benign proliferation of synovial tissue with TGCT representing the extraarticular version of PVNS. This may involve the tendon sheath, joint capsule, bursa or ligaments and the synovium contains macrophages, hemosiderin and multinucleated giant cells.3 Unrestricted proliferation of these giant cells can often cause loss of joint function and damage to adjacent bone. This osseous damage (seen in 15% of patients) makes this lower extremity tumor the most likely to firmly diagnose with imaging (plain radiographs and MRI).3 Patients will often present with increasing pain, loss of range of motion, and neurosensory symptoms. Principal treatment is usually resection, with possible need for total synovectomy. 3) Malignant Tumorous Lesions continued on page 27 Approximately 10%

Missouri Family Physician April - June 2013

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MAFP ASA Exhibitors

Thank you

>> 2013 ASA Exhibitors

The MAFP would like to recognize and thank the organizations who supported and participated in the 65th Annual Scientific Assembly in June. Join us in expressing our appreciation to the following:

AbbVie

MMIC

Anthem Blue Cross/Blue Shield

MO Health Professional Placement Services

ASBMR/The France Foundation

PDS Cortex

Children’s Mercy Hospital & Clinics

Sanofi Pasteur

Cox Health

Show Me Response - Missouri DHSS

Health Diagnostic Laboratory, Inc.

St. Jude Children’s Research Hospital

Ideal Protein

SuccessEHS

Missouri Army National Guard

United Allergy Services

Missouri Health Insurance Pool (PCIP)

U.S. Army Healthcare

Missouri Professionals Mutual (MPM)

26 Missouri Family Physician July - September 2013


Resident Grand Rounds/Poster Contest Winners mafp

Schwannoma continued from page 25

of soft-tissue sarcomas occur on the lower extremity,4 making it necessary to fully assess malignancy on the differential of a foot/ ankle lesion. The most common sarcomas of the lower extremity include synovial sarcoma, clear cell sarcoma and Ewing sarcoma.4 Like benign growths, they usually present as painless, enlarging masses and can grow fast or slow depending on the grade of the tumor. They tend to be non-tender, firm and well circumscribed and are more often large in size and fixed in nature. Workup should include plain radiographs which may show spotty calcifications, MR imaging, biopsy and likely workup for potential metastases.5,6 Treatment mainstay is en bloc resection of the tumor with wide margins and possible adjunct modalities (e.g. radiation therapy) depending on diagnosis.5 Conclusion Soft-tissue lesions of the lower extremity can be degenerative, posttraumatic, or neoplastic in origin. The patient in this case was found to have a rare benign tumor of the nerve sheath and had good clinical outcome following excision. A strong clinical foundation as well as good communication between primary care and foot/ankle surgical specialists is imperative to proper management of these soft tissue lesions. References 1. Kirby EJ, Shereff MJ, Lewis MM. Soft-tissue tumors and tumor-like lesions of the foot. An analysis of eighty-three cases. J Bone Joint Surg Am. 1989; 71:621-6. 2. Van Hul E, et. Al. Pseudotumoral soft tissue lesions of the foot and ankle: a pictorial review. Insights Imaging 2011; 2: 439-452. 3. Llauger J, et al. MR Imaging of Benign Soft-Tissue Masses of the Foot and Ankle. Radiographics 1998; 18: 1481-1498. 4. DeGroot H 3rd. Approach to the management of soft tissue tumors of the foot and ankle. Foot Ankle Spec. 2008;1:168-76. Review. 5. Van Vilet M et al., Soft tissue sarcomas at a glance: clinical, histological, and MR imaging features of malignant extremity soft tissue tumors. Eur Radiol 2009; 19:1499-1511. 6. Blackett J, Difficulties in diagnosing soft-tissue sarcomas: a case of synovial sarcoma of the foot. NZ Med Journal 2011;124: 83-87.

Resident Poster Contest Winners 1st Place - Jason Meler, DO & Kara Meler, DO (UMKC FMR) Comparison of GBS Prevalence at TMC Lakewood Nursery vs. TMC Hospital Hill Nursery 2nd Place - Jacob Masena, DO & Ryan Sears, DO (UMKC FMR) Group Interventions in Diabetes Care Does it Change Outcomes or Perceptions 3rd Place - Harveer Parmar, MD (Research FMR) Chromium & Diabetes Research Missouri Family Physician July - September 2013

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