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Official Publication of the Missouri Academy of Family Physicians

Family Physician

July - September 2014 Volume 33, Issue 3

2014 Family Physician of the Year, David Pulliam, DO pg. 18

Resident Grand Rounds Kenneth Tan, MD Casey Williams, MD pg. 14

Meet MAFP President, Daniel Purdom, MD pg. 16

Health Care Legislation Recap of 2014 Session pg. 24

MAFP Annual Fall Conference

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Missouri Family Physician July - September 2014

Join us for the 22nd Annual Fall Conference and SAM Working Group to be held at Big Cedar Lodge Ridgedale, Missouri

November 7-9, 2014 Early Bird Discount and Room Reservation Deadline Ovtober 6, 2014

Contents MAFP

Mark your Executive Commission Board Chair - Bill Fish, MD (Lake Ozark) President - Daniel Purdom, MD (Independence) President-elect - Peter Koopman, MD (Columbia) Vice President - Kathleen Eubanks-Meng, DO (Blue Springs) Secretary/Treasurer - James Stevermer, MD (Fulton) 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: Caroline Rudnick, MD Alternate: Sarah Cole, DO District 4 Director: Jennifer Scheer, MD Alternate: Vacant District 5 Director: Lucas Buffaloe, MD Alternate: Vacant District 6 Director: Jamie Ulbrich, MD Alternate: Vacant District 7 Director: Vacant Director: Vacant Alternate: Vacant District 8 Director: Mark Woods, MD Director: John Paulson, DO, PhD Alternate: Charlie Rasmussen, DO District 9 Director: Patricia Benoist, MD Alternate: Vacant District 10 Director: Mark Schabbing, MD Alternate: Steven Douglas, MD Resident Directors Imani Anwisye, MD Betsy Wan, MD (Alternate) Student Directors Amanda Williams Sarah Williams (Alternate)

Chapter Executive Leadership Program September 8-9, 2014 Las Vegas, NV

AAFP Annual Chapter Leadership Forum/National Conference of Constituencies Leaders (formerly ALF/NCSC) April 30-May 2, 2015 Sheraton Kansas City Hotel at Crown Center Kansas City, MO

AAFP Congress of Delegates October 20-22, 2014 Marriott Marquis, Washington, DC AAFP Annual Scientific Assembly October 21-25, 2014 Walter E. Washington Convention Center Washington, DC MAFP 22nd Annual (AFC) & SAM Working Group November 7-9, 2014 See page 22 for Big Cedar Lodge Ridgedale, MO Schedule of Events

AAFP Family Medicine Congressional Conference May 12-13, 2015 Renaissance Downtown Hotel, Washington, DC MAFP 67th Annual Scientific Assembly June 5-7, 2015 The Lodge at Old Kinderhook Camdenton, MO

MAFP Board & Commission Meetings November 8, 2014

AAFP National Conference of Family Medicine Residents & Students (NCFMRS) July 30 - August 1, 2015 Kansas City Convention Center, Kansas City, MO

AAFP State Legislative Conference November 14-15, 2014 New Orleans, LA

AAFP Congress of Delegates September 28 - October 3, 2015 Hyatt Regency, Denver, CO

MAFP Advocacy Day & Board Meeting February 24, 2015 Capital Plaza Hotel & State Capitol Jefferson City, MO

AAFP Annual Assembly September 29 - October 3, 2015 Hyatt Regency, Denver, CO MAFP 23rd Annual (AFC) & SAM Working Group November 2015 Big Cedar Lodge, Ridgedale, MO

Multi-State Forum February 28-March 1, 2015 Hotel: TBA, Dallas, TX

Inside this issue 4 Officer Reports & Annual Reports

29 Thank You ASA Exhibitors

12 Help Desk Answers

31 2014 Tar Wars Poster Contest Winner

Resident Case Studies

Amanda Hearn

14 Resident Grand Rounds

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


f (573) 635-0148

Kenneth Tan, MD Casey Williams, MD


16 Welcome New MAFP President

2 Physicians Professional Indemnity Association (PPIA)

18 Family Physician of the Year

5 Saint Luke's Marion Bloch Neuroscience Institute Symposium

Daniel Purdom, MD David Pulliam, DO

19 Membership Anniversaries 20 Members in the News 22 Fall Conference Schedule 23 Externship Essay

12 Family Physicians Inquiries Network 22 Saint Louis University Job Opportunity 23 Missouri Health Professional Placement Services

Mitchell Elting 27 FP Jobs Online 24 Health Care Legislation 2014 Session 32 Missouri Professionals Mutual (MPM) Pat Strader

28 ASA Photos 29 NCSC Experience Wael Mourad, MD

Missouri Family Physician July - September 2014


MAFP Outgoing Officer Reports

Kate Lichtenberg, DO, MPH, FAAFP 2013-2014 MAFP Board Chair


t is hard to believe that I have completed my time on the Board of the Missouri Academy of Family Physicians. The past 7 years have been full of changes for both family medicine and the Academy. We have developed and executed a 5-year strategic plan, our membership has grown (now at over 2,000 members), and our magazine won an award from the Missouri Society of Association Executives. Dr. Bill Fish assumed the Board Chair position at the annual meeting. I am confident that he will continue to lead the Academy in the right direction. Dr. Dan Purdom will serve you well during his presidency year. See our Twitter feed for a photo of Dr. Purdom in action at the Annual Leadership Forum (ALF) in Kansas City in April. Dr. Peter Koopman moves to President-Elect. His expertise in education (he also serves as one of our Education Commission Co-Chairs) and his attendance at the Family Medicine Congressional Conference (FMCC) in Washington DC

the past few years will keep us all better updated. We welcome Dr. Jim Stevermer as our new Secretary/Treasurer. He assumes the position from Dr. Tracy Godfrey, and we thank her for her service to the Academy. Dr. Stevermer will be an excellent steward of the Academy’s financial health. I would like to especially thank Dr. Arthur Freeland (Advocacy Commission), Dr. George Harris (Member Services Commission), and Dr. Jim Stevermer (Education Commission) for all of their time and dedication through the years as Co-Chairs of their respective Commissions. Please help me welcome Dr. Jamie Ulbrich (Advocacy Commission), Dr. Kathleen Eubanks-Meng (Member Services Commission), and Dr. Dana Granberg (Education Commission) for stepping up as our new Co-Chairs. Our future is bright with so many new leaders. Advocacy remains one of our top priorities and we held our Advocacy Day in Jefferson City again this year in conjunction

Check out the new MAFP website Follow us on Twitter @MO-AFP


Missouri Family Physician July - September 2014

with our February Board Meeting. We have a consistent presence at the Capitol thanks to our lobbyist, Pat Strader. She works tirelessly on our behalf. Our other big change over the past year has been the hiring of our new Executive Director, Kathy Pabst. We are excited to have her on board and know that more great things will be coming our way. Nancy Griffin and Laurie Bernskoetter (our veteran staff members!) held down the fort during our search for Kathy, and I am deeply grateful for their commitment and assistance during that time. It made my year as Board Chair much easier. I would like to thank our members for having the confidence in me to lead our Academy. I truly appreciate it. Finally, I would like to take a quick moment to thank my husband, Mike, and my children, Will and Sarah. They are a constant source of strength and support and I couldn’t do the things I do without them■

Outgoing Officer Reports MAFP

William Fish, MD, FAAFP 2013-2014 MAFP President


have enjoyed my year as President of the Missouri Academy, and I believe your board continues to serve our specialty well. Attending the Congress of Delegates and the Multi-State Advocacy Meeting for State Chapters, I see how fortunate we are in the state of Missouri on many fronts, but I also see the need of continued efforts to keep our legislators informed of issues. Many states have completely independent practice for Nurse Practitioners and greater inroads by other non-physician providers. Our Missouri legislators have, to date, appropriately sided with a higher level of education and experience. I testified twice before the legislature on tort reform, and this is an area where our physician colleagues are unified. The defense attorneys joined us in presenting what seemed to be well organized evidence for re-enactment of limits on non-economic damages, but the legislature did not provide us any relief. Plaintiff attorneys present emotional testimonials to distract from the evidence and it is important for you to continue to have dialog with your legislators on this issue and how it affects the physician workforce in our state. We cannot afford to lose more physicians to surrounding states with laws that have resulted in lower liability costs and less frequent nuisance suits that are expensive and take a large emotional toll on physicians. I give my thanks to our board who give time to maintain, and enhance, the quality of practice in our specialty. Thank you to all who take time to testify in Jefferson City. Thank you for maintaining your membership and for those who contribute to our Political Action Committee. These funds are critical in allowing us to present our case in the capitol. All of our members

are welcome to attend any board meetings. If you have an interest in serving on the board, let our staff know. If you haven’t already, consider joining our “Club Jefferson” representing Jefferson City and Thomas Jefferson, who adorns the two dollar bill. Being in “Club Jefferson” represents a commitment to contributing 2 dollars per week for the next year to our Political Action Committee. We are pleased to add Kathy Pabst to our talented professional staff. Kathy brings a great deal of administrative experience and we feel we have an incredible team. Thank you so much to Nancy Griffin and Laurie Bernskoetter for their excellent work and for keeping all of our projects running smoothly during our executive director search. Thanks, also, to Pat Strader, our lobbyist for keeping us informed on action, or lack thereof, in Jefferson City. Her organization, experience and knowledge have been invaluable in our advocacy efforts. Special thanks to Dr. Kate Lichtenberg for her service to our state Academy. She has put in countless hours for many years and her leadership over the past year went above and beyond to the benefit of the entire membership■

Send us your news! The Missouri Family Physician magazine welcomes your input. If you have "Members in the News" information you would like to share and include in the next issue, please submit newsworthy items for review to: See page 12 for current news about your colleagues. Missouri Family Physician July - September 2014


MAFP Outgoing Officer Reports President-elect Report Since the last board meeting, I participated in the interviews and selection process of our new Executive Director. We are very happy to have Kathy on Board. Daniel Purdom, MD

I also attended the Annual Leadership Forum in Kansas City Thursday, May 1st and Friday May 2nd. (I did not attend Saturday’s sessions due to my son’s graduation.) My focus for workshops was leadership and chapter operations. The workshops were very well done and informative.

Vice President Report

Peter Koopman, MD

My first year on the Executive Commission as Vice President has been informative and stimulating. I am honored to represent Missouri Family Physicians and our specialty.

As a new Executive Commission member, I would like to inform those I represent of my background. I have been involved in the AAFP since medical school in Pittsburgh, Pennsylvania and have advocated for Family Medicine’s relevance and importance my whole career. I currently am an Associate Professor of Clinical Family and Community Medicine at Mizzou and have served as faculty for 7 years. Prior to my academic career, I worked in a number of different practice settings. I spent 5 years caring for an underserved population in a rural town of 2,500 in Florida and 5 years in an urban practice in South Carolina serving half geriatric patients and half urgent care vacationers. 6

MAFP staff and board leadership attended the AAFP Annual Leadership Forum May 1-3. Missouri delegates to the National Conference of Special Constituencies are pictured above as well. NCSC was held at the same time. Pictured above, L to R: Laurie Bernskoetter, Nancy Griffin, Kathleen Eubanks-Meng, DO, Peter Koopman, MD, Kathy Pabst, Tess Garcia, MD, and Daniel Purdom, MD. Not picured are: Wael Mourad, MD, and Sudeep Ross, MD who also attended as NCSC delegates.

My wife Richelle, also a Family Medicine physician, and I made the decision to go to Charleston, South Carolina where she pursued a master’s degree in research and joined the faculty at the Medical University of South Carolina. During that time in South Carolina, I volunteered for the South Carolina Academy as a preceptor to medical students and caught the teaching bug. When my wife was offered an excellent research opportunity at Mizzou, I made the decision to join the faculty and try my hand at teaching. Last year I received the Outstanding Clinical Faculty Teacher award from the medical school. My current clinical setting in Columbia, to which I devote more than half my time, is a progressive suburban Family Medicine practice. My career thus far, with its different experiences, has reconfirmed repeatedly that Family Medicine is an essential part of a well-functioning health care delivery system, and I have seen that importance from numerous perspectives as a rural, urban and academic Physician. As your Vice President this year, I have learned many things which will help me better advocate for Family Medicine and also help me be a leader for the MAFP. These experiences have broadened my

Missouri Family Physician July - September 2014

understanding of Family Medicine’s promise and challenges. Attendance at the Multi-State conference in Dallas with leaders from many state chapters indicated how other states approach their academy business and showed both similarities and differences in topics important to each state. States, such as Colorado, which have allowed independent Nurse Practitioners have a different set of priorities with their issues related to scope of practice. Regardless of differing issues surrounding scope and access from state to state, our ability to work in teams to deliver care in a Patient Centered Medical Home (PCMH) model with a broadly trained Primary Care Physician as a leader in those teams, continues to be the model which has been shown to improve health care outcomes in multiple settings worldwide. Collaboration is part of the mission and value of the PCMH and the academy needs to continue to support structures and funding to allow that model to work most efficiently. For the fourth year straight, my attendance at the Family Medicine Congressional Conference (FMCC) in DC allowed me to continue to build relationships with our federal legislators. Given the discussion of fixing the flawed sustained growth

Officer/Annual Reports MAFP rate (SGR) formula of Medicare was off the table at the time of the meeting, the discussions and requests this year centered on primary care workforce and support. FMCC allows this voice to be heard and teaches us how to be most effective with our message. We also continue this type of advocacy locally during our Advocacy Day in Jefferson City and this has a similar impact. We may not always get what we want, but we need to continue to effectively advocate for our specialty as one of the primary roles for the Academy. As Vice President, I also attended the Annual Leadership Forum (ALF) of the AAFP in Kansas City with our staff and current President-Elect Dr. Daniel Purdom. I learned quite a bit about not-for-profit board membership policies, procedures, and leadership. This was my first time interacting with our new Executive Director, Kathy Pabst, and that interaction has assured me that the search committee made an excellent choice. Kathy will promote the vision and mission of the MAFP and we will move forward under her leadership. Our current excellent staff, Nancy Griffin and Laurie Bernskoetter, deserve great big kudos for all they accomplished without an Executive Director. Our current president, Dr. Bill Fish, deserves recognition for his leadership and drive in energizing and organizing this search process. Our outgoing board chair, Dr. Kate Lichtenberg, also deserves

recognition for all the work she did to allow this transition to happen and protecting the interests of our members and the Academy. It could not have happened so well without her. The ALF had multiple high notes including a session by the Robert Graham Center which presented data confirming the value of Primary Care and the PCMH to our health care system. Good research and data such as the Graham Center produces reinforces our anecdotes and helps to form policy that support and funds Family Medicine. I believe our Academy needs to continue to publicize such research and assist in its collection. As current co-chair of the Education Commission, the ASA at the Lake was well designed and an excellent educational conference. I am excited to continue to help bring forth new innovations and top notch speakers for our conferences in the future. I see CME delivery (as is medical education as a whole) to be a dynamic changing environment. There are many challenges to changing the status quo but hopefully our conferences will slowly introduce new helpful innovations that allow you not just to participate in CME but actually learn new important knowledge. As an academician at Mizzou, I am challenged daily to figure out how to better educate our medical students and residents and I hope to continue to bring those skills to help to better educate Missouri Family Physicians. Education

needs to continue to be a focus and priority for the Academy. As President Elect next year, I will continue to learn and acquire new skills to improve as one of your leaders for the academy. I look forward to working with and learning from Dr. Purdom during his President year. I will continue to promote collaboration, advocacy, research and education. I look forward to our future together as Family Physicians.

Secretary/Treasurer Report I've enjoyed my brief (so far) time on the Executive Board of the Missouri Academy. I think the Board and Academy are led by a thoughtful group with diverse experiences, all of James Stevermer, MD which helps guide us in our attempts to enhance the role of family physicians in Missouri. Past stewardship of our resources leaves the Academy in a solid financial situation in order to support this role.

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 2014 AAFP ALF/NCSC, MAFP was presented with the following Chapter Membership Awards: Highest percent retention of active members as of 12/31/13 (2nd place); Highest percent

retention of new physicians as of 12/31/13 (1st place); and Chapters at 100% for Resident Membership for 2013-2014 as of 3/31/14. In 2014, we join our MAFP members celebrating AAFP and/or MAFP membership anniversaries. Those who were present at the Annual Scientific Assembly were recognized at the Awards and Installation Dinner. A full listing of the Membership Anniversaries can be found on page 19

Necrology Report for April 2013 to 2014 Richard L. Bartley, MD (Springfield) Richard P. Bowles, MD (Kearney) James E. Campbell, MD (Macon) Billy G. Crayton, MD (Kansas City) James D. Humphrey, MD (Kansas City) Harold D. Lankford, MD (Mexico) W.H. Poggemeier, Jr., MD (St. Charles) Luis A. Reyes, MD (St. Louis)

Missouri Family Physician July - September 2014


MAFP Annual Reports Resident Report

Imani Anwisye, MD, MPH and Betsy Wan, MD

Excerpt from 2014 National Residency Matching Program Data – AAFP Match Summary and Analysis • In the 2014 National Resident Matching Program® (NRMP®) Match, family medicine residencies

filled 62 more positions (family medicine includes family medicine categorical, plus combined programs: emergency medicine-family medicine, family medicine-preventative medicine, medicine-family medicine, and psychiatry-family medicine) than in 2013 (3,000 vs. 2,938) • U.S. seniors matching to family medicine residencies increased by 42 (1,416 vs. 1,374). Family medicine residencies offered 70 more positions in the Match than the year prior, for a total of 3,132 positions offered (vs. 3,062 in 2013). This marks the fifth straight year that family medicine has increased positions offered and filled; beginning with an increase in 2010, family medicine residencies have increased positions offered by 577,

positions filled by 671, and positions filled with U.S. seniors by 333. • The fill rate for family medicine residencies in the NRMP Match has increased over the last decade to 95.8%, down only slightly from 2013 (96%), but up from 91.4% in 2010 and 82.4% in 2005. The fill rate for U.S. seniors is 45.2% in 2014, up slightly from 44.9% in 2013, and down slightly from the decade’s peak at 48.3% in 2012. • Of the primary care specialties, family medicine saw the largest increase in positions offered and filled. Family medicine consistently offers and fills the majority, about four-fifths, of all primary care positions.


Missouri Family Medicine Residencies – Intern Listing for Class of 2017

Tim Sirard, MD American Univ. of the Caribbean

Alex Meyer, DO AT Still University Kirksville

Cox Family Medicine Residency Meghan Blay, DO KCUMB

Shawn Stranckmeyer, MD Univ. of Medicine and Health Sciences

Perini Shah, DO University of North Texas

Steven Zinter, DO KCUMB

Research Family Medicine Caleb Baughn, MD UMKC

Wes Campbell, DO KCUMB Ian Cheyne, MD Univ. of Arkansas – Little Rock

Mercy Family Medicine Mihiret Belihu, MD Gondar College of Medicine

Angela Conklin, DO, MBA KCUMB

Catherine Moore, DO AT Still University Kirksville

Nida Dillon, DO KCUMB

Brett Mossberger, DO KCUMB

Alex Mazzaferro, MD St. Louis University

Katelyn Merando Falk, MD UMKC

Samantha Potter, DO, MBA KCUMB

Mallorie Rhymer, MD St. Louis University

Casey Gee, MD Univ. of Kansas School of Medicine


Missouri Family Physician July - September 2014

Daniella Boyer, DO KCUMB

Annual Reports/FHFM MAFP Harmandeep Khosa, MD Saba University School of Medicine

Andrea Bickerton, MD Howard University

Neil Bryan, MD University of Kansas

Brittani Moeller, DO KCUMB

Asa Chu, MD Saba University

Jayme Decker, DO, MS KCUMB

Adam Morawski, MD Saba University School of Medicine

Veronica Conaway, MD University of Missouri Columbia

Kevin Gray, MD UMKC

Joshua Richards, DO KCUMB

Chase Ellingsworth, MD University of Missouri Columbia

Emily Grewe-Nelson, DO Oklahoma State University

Genna Siemons, MD Univ. of Kansas School of Medicine

Erin Pearson, MD University of Missouri Columbia

Cierra Johnson, MD, MA University of Kansas

Benjamin Skoch, DO KCUMB

Carlos Rubio-Reyes, MD Universidad Autonoma de Guadalajara

Eli Katz, MD, MS University of Iowa

Merlin Sunny, DO KCUMB

Andrea Schuster, MD University of Missouri Columbia

Christine Lilly, DO, MS KCUMB

St. Louis University Mohammed Dalal, DO Univ. of Pikeville - Kentucky College of Osteopathic Medicine

Ben Stevens, MD University of Arkansas

Nicholas J Miller, DO KCUMB

Howard Tseng, MD American University of the Caribbean

Michael Moreland, DO Texas College of Osteopathic Medicine

Kenetra Hix, MD Univ. of Tennessee College of Medicine Memphis

Megan Warhol, DO KCUMB

Colleen Quinn, MD Southern University of New York at Buffalo

Kanika Turner, MD Saint Louis University School of Medicine

Christine Wilson, DO AT Still University Kirksville

Rachel Seymour, MD, MSc University of Kansas

Preethi Schmeidler, MD Univ. of Kansas School of Medicine

University of Missouri – Kansas City Hailey Avila, DO Western University of Pacific

Aniesa Slack, MD University of Kansas

Medical School Student Graduate entering Family Medicine Residency, support the summer Externship Scholarships, and support the Tar Wars ® Program:

School, July 7 to August 1 externship at SLU FMR; Kimberly Olson from St. Louis University Medical School, June 16 to July 11 externship at UMKC FMR; Michael Tarkey from St. Louis University Medical School, June 2 to June 27 externship at Mercy FMR

University of Missouri- Columbia John Ballantyne, MD American University of the Caribbean

Thank you to the following individuals for their generous donation to the Family Health Foundation of Missouri. David Barbe, MD Miranda Huffman, MD Peter Koopman, MD Carl Myers, MD Darryl Nelson, MD Donald Potts, MD F. David Schneider, MD Michael Wulfers, MD Donations help sponsor students to attend the MAFP Annual Scientific Assembly (ASA), offset expenses for the scholarship to NCFMRS each year (1 Resident and 1 Student), fund the scholarship for the Top

Whitney Trusty, MD University of Kansas

Scholarships Five top graduating medical students who are entering family medicine residencies were awarded certificates and scholarships of $500 each. Scholarships were awarded to: AT STILL – Christine Wilson, DO KCUMB – Amanda Kern, DO Mizzou – Alexander Zweig, MD SLU – Kanika Turner, MD Wash U – Jennifer M. Jupitz, MD Summer Externships With AAFP Foundation matching funds, the FHFM sponsors four-week summer externships. This year:, Mitchell Elting from UMKC School of Medicine, May 19June 13 externship at Research FMR; Tory Nestler from St. Louis University Medical

Tar Wars Tar Wars continues to be a very successful program. This year’s poster contest had approximately 30 submissions! See page 31 for names of the Missouri Tar Wars poster winners. The first place winner 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.

Missouri Family Physician July - September 2014


MAFP Annual Reports FMIG Reports Regarding Match, UMKC had 3 students match into Family Medicine. Of those 3, 2 will be completing residencies in Missouri.

Sarah Williams and Amanda Williams

ATSU Kirksville ATSU is focusing on community involvement, as well as educating their student body on primary care. This year, they have participated in multiple 5K events to raise funds for United Way, as well as promote health and wellness within the community. ATSU held their annual Health Fair to provide physicals and OMT for the community. The FMIG also held their Lecture Series, open to the entire student body, to educate students on multiple primary care topics. Regarding Match, UMKC had 32 students match into Family Medicine. Of those 32, 6 will be completing residencies in Missouri. University of Missouri-Kansas City UMKC has seen an increase in Family Medicine interest secondary to the work of their FMIG chapter. This spring, they organized a screening of “Escape Fire”, open to students, residents, physicians and the general public for increased awareness in primary care. They have also involved the entire student body at UMKC-SOM by incorporating suturing workshops, “Final survival” nights, and “strolling through the match” events. The UMKC FMIG is devoting much of their time to community projects as well. Recently, they are working with RBI, an organization that provides free physicals for children so they may participate in community-organized sports.

University of Missouri-Columbia Mizzou continues to promote Family Medicine among their large student body. During Primary Care Week, the FMIG organized lectures in geriatric, pediatric, and rural family practice. They have conducted casting workshops and a post-match panel discussion this spring. Mizzou has developed a student position on the MU Healthcare Palliative Committee. They have also introduced the AMA's Doctor Back to School program to Columbia and surrounding area. This is a program where students visit schools and talk about a career in medicine. Community involvement has included continuing Ronald McDonald House Dinners for families staying there as well as reaching children in Columbia and Lebanon, MO through the MU Tar Wars program. Regarding Match, Mizzou had 11 students match into Family Medicine. Of those 11, 4 will be completing residencies in Missouri. Washington University The FMIG at WashU is small, but has been working with SLU to encourage interest in Primary Care. Together, they participate in Family Medicine Grand Rounds. Washington University actively participated in Primary Care Week by developing a lecture series and PCMH model. The FMIG continues to participate in school activity fairs to share their mission. They have created an FMIG listserv for the first time. Over 50 students signed up for the email list. They have been able to use this listserv to send out interesting articles or updates from AAFP as well as advertise events. Regarding Match, Washington University had 3 students match into Family Medicine.

10 Missouri Family Physician July - September 2014

St Louis University SLU FMIG continues to be active in developing lectures on a weekly to biweekly schedule that includes the financial, political and scientific implications of primary care. Workshops for this year have included residency fairs, post-match panels and procedure clinics. FMIG is also a part of the Primary Care Interest Group that brings together the leaders of the Internal Medicine, Pediatric and Family Medicine Interest Group to coordinate National Primary Care Week, a primary care mentorship program, undergraduate procedure night and a research in primary care talk. The SLU FMIG has been involved in the community through their Alzheimer’s project, Time Slips, and the health screening services, Community Health Coalition. Regarding Match, SLU had 15 students match into Family Medicine. Of those 15, 4 will be completing residencies in Missouri. KCUMB The KCUMB primary care groups and FMIG have held monthly lectures and workshops to raise awareness and educate students, specifically MS1 and MS2s, regarding Family Medicine and common primary care topics, including hospices, geriatrics and chronic medical conditions. Within the community, they have established school physicals for underprivileged children so that they may participate in organized sports. They have also been participating in Heart to Heart International to create care packets for children, diabetic screening workshops within the community, and first aid booths for students and community members. Regarding Match, KCUMB had 47 students match into Family Medicine. Of those 47, 16 will be completing residencies in Missouri.

Annual Reports MAFP Executive Director Report As your new Executive Director, my first day with MAFP was April 14 and I am excited to be part of such a prestigious group. My first 6 weeks were filled with Kathy Pabst learning about the organization structure and culture of AAFP and MAFP, planning the ASA, familiarizing myself with key issues in the legislature and MAFP, and getting acquainted with the board and staff (Nancy and Laurie are great to work with!). I appreciate your patience as I learn and grow with MAFP. Every day is better than the previous (with some challenges encountered), and I look forward to working with each of you. Multi-State Forum (February 28-March 1, 2014) Peter Koopman, MD and Bill Fish, MD, attended the Multi-State Form which was held in Dallas, TX. Each chapter rotates on planning this event, and the Iowa Academy of Family Physicians was the hosting chapter this year. Missouri will be the hosting chapter in 2018. FMCC (April 7-8, 2014) MAFP members, Emily Doucette, MD, Peter Koopman, MD, Keith Ratcliff, MD, Ingrid Taylor, MD, and Todd Shaffer, MD, attended the Family Medicine Congressional Conference. Please reference the reports from Dr. Bill Fish and Dr. Peter Koopman for details about this year’s conference. The FMCC is an opportunity to better understand federal advocacy, learn about the current priorities for family medicine, and receive practical, hands-on experience with the legislative process. In addition, the delegates met with the Missouri senators and representatives to discuss primary care, workforce development and other issues.

ALF (April 30-May 3, 2014) MAFP staff attended the Annual Leadership Forum in Kansas City. The MAFP President Elect, Vice President, and Executive Director attended sessions on association management presented by Bob Harris, CAE. Many concurrent sessions were available for staff, board members and physicians. Overall, the conference was very good with ideas and processes that will be adopted by MAFP. Kathy Pabst attended a one-half day session presented by AAFP staff on meetings, marketing, communications, public relations, social media and students/residents. She will return to the AAFP office later this year for executive director orientation which will be held with one other new director. AAFP has changed the name of this conference to Annual Leadership Conference for Current and Aspiring Leaders with two tracks: Annual Chapter Leadership Forum and National Conference of Constituency Leaders. The structure will remain the same. NCSC (April 30-May 3, 2014) MAFP delegates selected to attend the NCSC conference were:

Reception was held Friday, August 8 from 6:30 - 8:00 pm at the Midland Theatre in Kansas City, MO. This is where the students and residents elect their MAFP Board representatives. Congress of Delegates (October 22-24, 2014) AAFP Delegates Darryl Nelson, MD and Larry Rues, MD, along with Alternate Delegates Bruce Preston, MD and Keith Ratcliff, MD, will be attending this year’s meeting AAFP Congress of Delegates in Washington, DC. A report from the delegation will be provided after the conference. ASA The Education Commission has done an excellent job of selecting speakers and timely topics to make this an excellent conference. Nancy Griffin and Laurie Bernskoetter, MAFP staff, have been attentive to the details for this conference to be a success. Strategic Planning The current strategic plan expires in 2015. We will need to begin thinking about the planning process at our November meeting.

• Women – Kathleen Eubanks-Meng, DO • Minority – Wael Mourad, MD • New Physician – Heather Toney, DO (cancelled due to family emergency) • IMG – Sudeep Ross, MBA, MD • GLBT – Tess Garcia, MD NCFMRS (August 7-9, 2014) Arrangements were made for students and residents to attend this year’s conference. Based on the MAFP rotation cycle, University of Missouri-Kansas City sent a student delegate (Jenny Eichhorn) and Mercy Family Medicine Residency’s is sending a resident (Jennifer Allen, MD). In addition, Missouri family medicine residency programs created a banner to be displayed at Missouri Street in the exhibit hall. The Missouri Missouri Family Physician July - September 2014


MAFP Help Desk Answers About HDAs - Resident authors work directly with a physician faculty mentor as “author teams”. Residencies meet RRC requirements, and many programs have developed their faculty into local evidence-based medicine experts!

Is screening for melanoma effective in primary care? Evidence-Based Answer

So far, education to promote self-screening has not improved mortality rates from melanoma (SOR: B, prospective cohort). There remains no clear consensus on the public health impact of population-based skin cancer screening; a large trial is currently underway. In 2012, the National Cancer Institute projected that 76,000 Americans will be diagnosed and 9,200 will die from malignant melanoma of the skin.1 The Cancer Research Campaign (CRC), a prospective cohort trial, implemented a self-detection health program in 1981 within England and Scotland to assess the effect of patient education on cumulative and annual melanoma mortality.2 The intervention area consisted of 6 health districts and 1 health board chosen because of the presence of local health registries. The intervention consisted of dissemination of a 7-point checklist (CRC Mole Watcher leaflet) to inform patients aged 15 to 74 years about early markers of melanoma and advise those with suspicious lesions to follow up with general practitioners. The intervention group was considered to be those patients to whom the leaflet was mailed (whether they read it or not); the control group lived in the intervention area or other nearby health districts in England and Scotland. Over a period of 15 years, there was no significant mortality difference between patients selected to receive the leaflet program (N=2.9 million) and control groups (N=30 million) after adjusting for pre-intervention rates of melanoma (risk ratio [RR] 1.2; 95% Cl, 0.9–1.7 in men; RR 0.9; 95% Cl, 0.7–1.3 in women).2 A pilot RCT is underway in Australia to address the effect of community-based population skin cancer screening on melanoma mortality.3 This trial randomized 560,000 adults older than 30 years within 44 communities in Queensland, Australia to participate in a 3-year structured primary care–based skin cancer screening program or usual practice. The first phase of this study included 9 intervention communities (N=35,000) and 9 control communities (N=28,000). Interventions included community education to promote screening, whole-body skin examinations by general practitioners, and specific skin cancer screening clinics. After 12 months of follow-up, screening participation increased 2.5 times in the intervention group. In the control groups there was no change (no P value provided). Melanoma mortality results are pending from the planned 15-year study.3 12 Missouri Family Physician July - September 2014

May 2014 EBP

The US Preventive Services Task Force (USPSTF) has concluded that evidence is insufficient to recommend for or against screening with a full-body skin examination for squamous cell, basal cell, or melanoma skin cancer in the general population (Grade I, current evidence is insufficient to assess the balance of benefits and harms).4 Kelly MacArthur, BS Laura Morris, MD, MSPH University of Missouri Columbia, MO 1.

2. 3. 4.

Howlader N, et al. SEER Cancer Statistics Review, 1975–2009. Accessed April 14, 2014. [STEP 5] Melia J, et al. Br J Cancer. 2001; 85(6):803–807. [STEP 2] Aitken JF, et al. J Med Screen. 2002; 9(1):33–37. [STEP 2] Wolff T, et al. Ann Intern Med. 2009; 150(3):194–198. [STEP 1]

From the authors who bring you HelpDesk Answers comes a relevant, concise, and clinically useful journal to assist you in delivering the best care to your patients –all without the bias of industry support. Evidence-Based Practice is published monthly by the Family Physicians Inquiries Network. 12 issues and 48 PRA Category 1 CME CreditsTM $119 Missouri Family Physician Reader or $59 FPIN Member To subscribe, or view a sample issue, visit or call 573-256-2066.

Help Desk Answers MAFP

How often should cholesterol screening be done in low risk adults? Evidence-Based Answer

The optimal interval for screening is uncertain. On the basis of panel guidelines and expert opinion, a reasonable option would be every 5 years (SOR: C) Shorter intervals can be considered for people who have lipid levels close to those warranting therapy, and longer intervals for those not at increased risk who have had repeatedly normal lipid levels. When to begin screening in low risk adults is also unclear. ATP III recommends beginning routine screening at age 20. USPTF recommends screening men at age 35, and women aged 45 with increased risk factors for CVD. According to the National Cholesterol Education Program's Adult Treatment Panel III (ATP III), a fasting lipoprotein profile (total cholesterol, LDL-C, HDL-C, and TG) is recommended in all adults over the age of 20 once every 5 years. This report is sponsored by the National Institutes of Health, and endorsed by the American Heart Association. Certain risk factors were identified for coronary heart disease (CHD) as follows; cigarette smoking, hypertension, low HDL cholesterol, family history of premature CHD, age. Since risk categories change slowly over time, the panel judged that lipid measurements once every 5 years are adequate in otherwise low-risk persons. More frequent measurements are required for persons with multiple risk factors or, in those with 0–1 risk factor, if the LDL level is only slightly below the goal level. There was no published research or trial identified to guide the recommendation other than panel judgment. The USPSTF made an update to their lipid screening recommendations in 2008. To guide the USPSTF in updating its 2001 recommendations, they reviewed evidence relevant to discrepancies between the recommendations of ATP III and USPSTF. They searched randomized controlled trials and observational studies published between December 1999 and February 2005. A key question raised in this update was directed at the optimal screening interval. The researchers did not identify new evidence relevant to the appropriate interval to screen for hyperlipidemia in the general population, or in subgroups of the general population. They make no recommendation on treatment interval. Their recommendations are as follows: Screening men: The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men 35 years and older for lipid disorders. The USPSTF recommends screening men 20 to 35 years of age for lipid disorders if they are at increased risk of CHD. Screening women at increased risk: The USPSTF strongly recommends screening women 45 years and older for lipid disorders if they

June 2014 EBP

are at increased risk of CHD. The USPSTF recommends screening women 20 to 45 years of age for lipid disorders if they are at increased risk of CHD. Screening young men and all women not at increased risk: The USPSTF makes no recommendation for or against routine screening for lipid disorders in men 20 to 35 years of age, or in women 20 years and older that are not at increased risk of CHD. Recommendations from other specialty groups are as follows: The American Academy of Family Physicians updated their recommendations in October of 2012 to match those of the USPSTF.

The American College of Obstetricians and Gynecologists recommends screening women every 5 years beginning at age 45; screening is recommended for women aged 19-44 based on risk factors. Sheldon Johnson, DO Peter Danis, MD Mercy Family Medicine Residency St. Louis, MO 1. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults JAMA. 2001;285(19):2486-2497 2. U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults: U.S. Preventive Services Task Force Recommendation Statement. June 2008. http://www. Accessed Jan 4th 2013 3. American Academy of Family Physicians summary of policy recommendations for periodic health examinations. Available documents/clinical/CPS/rcps08-2005.Par.0001.File.tmp/ October2012SCPS.pdf Accessed Jan 4th 2013. 4. Primary and preventive care: periodic assessments. ACOG Committee Opinion No. 292. American College of Obstetricians and Gynecologists. Obstet Gynecol 2003;102:1117-24.

Missouri Family Physician July - September 2014


MAFP Resident Grand Rounds

Intralesional steroid injections for the treatment of plantar fibromatosis: a Case Report Kenneth Tan, MD Casey Williams, MD University of Missouri - Columbia Family Medicine ABSTRACT Plantar fibromatosis is a disease of unknown etiology that is characterized by benign fibrous tissue growth within the plantar fascia or aponeurosis1. This disease process can present as single or multiple nodules (fibromas) or as an infiltrating mass (fibromatosis).2 Although it is a relatively uncommon condition, when present, plantar fibromatosis can cause significant pain and difficulty walking. Treatment often involves surgical excision, which is not without potential postoperative complications including a risk for recurrence3 (in some reports as high as 60 percent).4 This case report highlights a potential alternative to surgery that involves intralesional steroid injections, a practice neither well studied nor understood. In this case, a series of three monthly intralesional injections of a 3:1 mixture of triamcinolone acetonide 40mg/mL and 1% lidocaine without epinephrine over a 4 month period resulted in significant improvement (reduced pain and size) of a patient’s plantar fibroma.

centimeters. The lesion was non-mobile and slightly tender to palpation. An ultrasound (Figure 1) was obtained and showed a 1.5 x 0.5 x 1.4 cm, solid, heterogeneous, predominantly hypoechoic lesion on the plantar aspect of the foot in the region of the first metatarsal. Differential diagnoses included plantar fibroma, giant cell tumor of tendon sheath, or hemangioma. An MRI of the left foot (Figure 2) was then obtained for further evaluation and showed a 0.5 x 0.2 x 0.6 cm nodular thickening of the plantar fascia, consistent with nodular plantar fibromatosis. The patient returned to clinic two weeks later to discuss the diagnosis and treatment plan. After all treatment options were discussed, the patient decided to undergo a trial of intralesional steroid injections.

Kenneth Tan, MD

Her main concerns with surgical treatment included cost, pain and recovery time, and potential for post-operative complications. Verbal informed consent was obtained from the patient, and the lesion was injected with 0.7cc of a 3:1 mixture of triamcinolone acetonide 40mg/mL and 1% lidocaine without epinephrine, the same mixture used by Pentland et al.3 Over the next 4 months, the patient saw significant decrease in the size of the lesion (and subsequently decreased pain) with monthly intralesional steroid injections. She received a total of 3 injections over this timeframe. Based on serial physical exams, the lesion decreased from its original size of approximately 1 x 1 cm to 0.2 x 0.2 cm by the end of treatment. The patient reported no further pain after the third injection, and the lesion had become non-palpable, so no further injections were performed. To this day, more than 3 months later,

Figure 1. Ultrasound of lump on plantar surface of left foot

CASE REPORT A 60 year old Caucasian female with a past medical history significant for hypertension, generalized anxiety disorder, and tobacco abuse presented to clinic with a 6 month history of an enlarging lump on the plantar surface of her left foot. She reported an insidious onset of the lump and denied any preceding trauma or injury to the area. The patient described increasing pain and difficulty with ambulation secondary to the lesion. On physical exam, the patient had a hard, dense lump at the base of the first metatarsal on the plantar surface of her left foot, measuring approximately 1 x 1 14 Missouri Family Physician July - September 2014

Casey Williams, MD

Resident Grand Rounds MAFP the patient reports she is pain free, and that the lesion remains small and hardly noticeable. DISCUSSION Epidemiology: Plantar fibromatosis, also known as Ledderhose disease, is a relatively uncommon disease that affects less than 200,000 Americans.5 Some authors, however, have suggested that plantar fibromatosis may affect more of the population than previously thought – approximately 25 percent of middle-aged or elderly individuals, which is also the age range of highest prevalence.5 Men are thought to be affected twice as often as women, and bilateral involvement occurs in approximately 25 percent of cases6. Pathophysiology: The exact etiology of this condition is unknown. On the microscopic level, plantar fibromas are composed of highly differentiated fibroblasts that grow in an infiltrative manner.7 Various studies have suggested that an increased release of growth factors such as insulin-like growth factor I, basic fibroblast growth factor, platelet-derived growth factor, and transforming growth factor-B (TGF-B) may play a role in the development of this disease.8,9 Of note, repeated trauma, alcohol use, chronic liver disease, diabetes, Figure 2. MRI of the left foot showing nodular thickening of the plantar fascia, consistent with nodular plantar fibromatosis

and seizure disorder have been reported in association with the development of these lesions.10 In addition, there is thought to be an association between plantar fibromatosis and other fibroproliferative disorders such as Peyronie’s disease and Dupuytren’s contracture of the hands.5 Clinical manifestations and diagnosis: Plantar fibromatosis typically presents as a slow-growing nodule or multiple nodules in the plantar fascia with initial symptoms of local pressure, swelling, and formation of the node.11 The lesion usually remains asymptomatic until it becomes large enough when direct pressure from standing causes pain1. Although rare, the late stage of this condition is characterized by the formation of contractures.11 Diagnosis can be made on clinical examination, although ultrasound and magnetic resonance imaging (MRI) are useful to confirm the diagnosis.12 Of note, plantar fibromas can be locally aggressive but do not metastasize.12 Management: Treatment is mainly symptom-oriented. For mild cases, anti-inflammatory drugs and orthopedic insoles can be used for pain relief and comfort; these measures, however, do not prevent the progression of the disease.11 Steroid injections have been used as alternative treatment,

although the mechanism of action is not well understood. There is some thought that steroids act to decrease fibroblast proliferation and increase fibroblast apoptosis.13 Steroids are also known for their dermal atrophy effect and ability to inhibit collagen synthesis, which could explain this response.3 One of the early studies that investigated intralesional steroids and their effect on plantar fibromas showed a significant response after 3-4 months of steroid therapy.3 Another study showed a success rate (defined as the lack of recurrence) of 50 percent within the first 3 years after intralesional steroid injections.14 If the aforementioned conservative measures fail, x-ray irradiation or surgery can be considered.11 Irradiation usually involves 2 irradiation cycles. Heyd et al 15 reported irradiation resulted in complete remission of nodes in 33.3% of cases and partial reduction in 54.5% of cases. Surgery – involving local excision, wide excision, or complete fasciectomy – has an overall estimated recurrence rate of 60 percent,4 but can significantly improve pain and mobility when successful. CONCLUSION Plantar fibromatosis is a condition characterized by benign fibrous growths in the plantar fascia and, when present, can cause significant pain and decreased mobility. Conventional treatment options include pain control (with medications or orthopedic insoles), intralesional steroid injections, x-ray irradiation, and surgery. This case report highlights the option of using intralesional steroid injections to treat plantar fibromas, the mechanism of which is not well understood, but in this case, led to significant improvement (reduced pain and size) of a patient’s plantar fibroma, without the risks involved with more invasive methods such as radiation or surgery. More research and long-term studies would be beneficial, but case reports such as the one presented here illustrate the importance of considering intralesional steroid injections, simple office procedures family physicians can perform, as potential treatment for plantar fibromatosis continued on page 17

Missouri Family Physician July - September 2014


MAFP President

Meet New 2014-2015 MAFP President Daniel Purdom, MD, FAAFP Daniel Purdom, MD, FAAFP, of Liberty, Missouri, was installed as the 66th President of the Missouri Academy of Family Physicians (MAFP) during the Awards and Installation Dinner in conjunction with MAFP’s Annual Meeting in Lake Ozark, Missouri, on June 7, 2014. Dr. Purdom is a board certified family physician who resides in Liberty, Missouri with his wife Karyn. Dr. Purdom is a clinical associate professor at the University of Missouri - Kansas City School of Medicine and has served as the faculty advisor for the Sojourner Clinic, a student-run free clinic for the homeless in downtown Kansas City, for the past ten years. He also serves as the medical director of a community health center and as the medical director of the Clay County Health Department. Dr. Daniel Purdom never repay. That’s the accepted the gavel at the first that we have to do. ASA Awards Dinner In Missouri, we can do and will serve as the this by supporting the Academy’s 2014-15 expansion of Medicaid. President. Dr. Purdom’s The second thing acceptance speech reflects we need to do is rise his professionalism, up and defend our dedication, and profession. There compassion for family are very few dates medicine and patients. that I am good at His remarks are remembering, but I summarized below: always seem to know Almost 26 years when the Missouri ago, I was sitting in an legislature goes into auditorium in Augusta, session and when it is Georgia about to graduate Family members who joined in celebrating Dr. Purdom's installation are pictured above, left to right: finally over. We will Dr. Purdom and his wife, Karyn (seated in front) and Ramez Alnazer, son-in-law, Sarah Alnazer, from medical school. I go to the legislature to had the pleasure this year daughter, Eli Purdom, son, Rees Purdom, son, and Judy and Jack Hill, mother and stepfather. defend our profession of watching two of my and protect our children graduate from college and when patients who have come through the ACA patients. We don’t have a choice. We’ve they say that phrase, “will the candidates Exchanges…it’s like practicing in Germany. got to take on that fight. We think we can please rise,” your heart beats a little faster. I We have the American system where we legislate away our competition. That will thought back to that day for me and it was have employer based healthcare. And even not happen. We can protect our patients, a mixed blessing. I finished medical school, some of our patients compare to living we can protect our profession, but we but also the day before I told my father that in the third world. I saw a patient, who cannot regulate away competition. But I can he had an inoperable cancer of the lung. came in, who had put off getting medical tell you this, for the people who think they And so I was faced with a lot of choices. care because she was uninsured, and had can compete with us, whether it is nurse What I learned from that experience was rectal bleeding and fecal incontinence for practitioners or the chiropractors, I have a somehow we don’t always know the right months. I felt that hard firm mass when I simple answer for them. Bring it, because thing to do. Tradition says, rise up, step did her exam…our working poor deserve we are the best prepared to provide care of forward and grasp the opportunity…that’s our support. the citizens of this state. what I did that day. There are four things that I think we The third thing we have to rise to is to Practicing medicine in Missouri is a should rise up for and represent. shape the future of our profession. Right fascinating thing. If you want a tour of The first is that we should rise up to now medical schools are saying that we medicine of the world, come to Missouri. represent the poor. Our medical schools don’t have enough docs, we need more Missouri has socialist medicine, government frequently care for those who didn’t have docs. Expanding medical school class size run, through the VA. If you want a single many options for care. They said you earned dramatically, but nobody is saying what payer system like Canada, take care of a living, your profession, on the bodies and kind of docs do we need. We some Medicare patients. We now have minds of the poor. That is a debt we will have to be able to shape that 16 Missouri Family Physician July - September 2014


Resident Grand Rounds MAFP

Plantar Fibromatosis continued from page 15

before more invasive measures. References 1. Wheeless CR, van der Bauwhede J. Wheeless’ Textbook of Orthopaedics. 2007. Ledderhose disease: plantar fibromatosis. 2. Chokshi FH, Jose J, Clifford PD. Plantar fibromatosis. Am J Orthop. 2009;38(9):475-6. 3. Pentland AP, Anderson TF. Plantar fibromatosis responds to intralesional steroids. J Am Acad Dermatol. 1985;12(1 Pt 2):212-4. 4. Van der veer WM, Hamburg SM, De gast A, Niessen FB. Recurrence of plantar fibromatosis after plantar fasciectomy: single-center longterm results. Plast Reconstr Surg. 2008;122(2):486-91. 5. Fausto de souza D, Micaelo L, Cuzzi T, Ramos-e-silva M. Ledderhose disease: an unusual presentation. J Clin Aesthet


conversation. Todd Shaffer, MD, has been involved in looking at our manpower reports for the state. Our message is not that we need more primary care providers. Our message is not that we need more primary care physicians. Our message is that our state and our nation need and deserve more family physicians. And that’s the message you will hear. Finally, we have to rise to the need of our patients and meet them where they are. I tell this story for our students because it reflects in me why we practice medicine. I had gone back to my hometown as a new physician. A local couple’s wife was in the hospital dying of breast cancer. She survived the cancer, but the chemotherapy killed her heart. She was in the ICU and she was trying to make it to her son’s graduation. Their son was very precious to them because he had almost drowned. That was her last wish. One of my colleagues who was caring for her had to go out of town, but had written the orders. “They are going to take her off her drips, her husband will take her

Dermatol. 2010;3(9):45-7. 6. Allen RA, Woolner LB, Ghormley RK. Soft-tissue tumors of the sole with special reference to plantar fibromatosis. The Journal of Bone & Joint Surgery. 1955 Jan;37(1):14-26. 7. Durr HR, Krodel A, Trouillier H, Lienemann A, Refior HJ. Fibromatosis of the Plantar Fascia: Diagnosis and Indications For Surgical Treatment. Foot & Ankle International. 1999;20(1):13-17. 8. Zamora RL, Heights R, Kraemer BA, Erlich HP, Groner JP. Presence of growth factors in palmar and plantar fibromatoses. J Hand Surg Am. 1994;19(3):435-41. 9. Murrell GA, Hueston JT. Aetiology of Dupuytren's contracture. Aust N Z J Surg. 1990;60(4):247-52. 10. Kulkarni V. Textbook of Orthopaedics and Trauma. Jaypee Brothers Publishers; 2009: 2352. Dupuytren’s contracture.

11. Veith NT, Tschernig T, Histing T, Madry H. Plantar fibromatosis-topical review. Foot Ankle Int. 2013;34(12):1742-6. 12. Pasternack WA, Davison GA. Plantar fibromatosis: staging by magnetic resonance imaging. J Foot Ankle Surg. 1993;32(4):390-6. 13. Meek RM, Mclellan S, Reilly J, Crossan JF. The effect of steroids on Dupuytren's disease: role of programmed cell death. J Hand Surg Br. 2002;27(3):270-3. 14. Ketchum LD, Donahue TK. The injection of nodules of Dupuytren's disease with triamcinolone acetonide. J Hand Surg Am. 2000;25(6):1157-62. 15. Heyd R, Dorn AP, Herkströter M, Rödel C, Müller-schimpfle M, Fraunholz I. Radiation therapy for early stages of morbus Ledderhose. Strahlenther Onkol. 2010;186(1):24-9.

to the football field, and she will see her son graduate and they will come back…just be available if they have any questions.” Sure, sounds easy enough. I get a call and she was having trouble breathing. I said, “Well, ok, don’t give up. Get her back on the drips and see what happens.” I didn't know the right thing to do, how do you handle this? She was able to sit up. And I said, “It seems to me that if you can sit up, then you can go to the football field.” I looked at the nurses, because I’m a young doc, foolish and I don’t know any better, and I say, “I need new batteries on all these pumps… we are going to the football field.” Well the nurses scrambled like fighter pilots and mission accomplished. My next question was how am I going to get her there? I called a transport service, shared the story, and they were there to help…at no charge. We get to the football field and the driver said something to the police officer, the gate swings open, and we pull onto the field, down to the goal line. The back of the van facing the stage, they open the back door of

the van and they watched their son graduate. When we took her back to the hospital that Friday night, you would have thought we landed a person on the moon. When she died that Sunday morning, we knew we had seen a life well lived. I tell that story because it taught me two things. One, when we try to do what’s best for our patients, there are all kind of people who will help us make it happen. Don’t be afraid. The other thing it always reminds me of is what a great privilege it is to participate in the lives of our patients in such a way. So those are the four things we are going to rise for. We are going to be a voice for the poor that is what I do. We are going to defend our profession. We are going to shape our future. And we are always, always going to serve our patients. I want to thank you for this honor to serve as your president.

Missouri Family Physician July - September 2014


MAFP Family Physician of the Year

Higginsville Physician Named MAFP Family Physician of the Year The Missouri Academy of Family Physicians (MAFP) presented David Pulliam, DO, of Higginsville, Missouri, with the 2014 Family Physician of the Year Award at the Academy’s 66th Annual Scientific Assembly held June 6-7, 2014 in Lake Ozark, Missouri. Dr. Pulliam was chosen as the award recipient by a committee of family physicians from nominations made by patients, community members, and fellow physicians. Dr. Pulliam served in the United States Air Force where he held the rank of Major and was chief of the family practice department, deputy chief of hospital services, and officer in charge of aerospace medicine. He has taught medical and nursing students and has been a Family Medicine clinical preceptor at University of Missouri in Columbia and Kansas City, University of Health Sciences in Kansas City, Kirksville College of Osteopathic Medicine, and the University of Central Missouri School of Nursing. Dr. Pulliam is a

graduate of the Kirksville College of Osteopathic Medicine, is ABFM certified in Family Medicine, and is an AAFP Fellow. Dr. Pulliam is involved in many local, state, and national organizations including the National Center for Fathering, board member of the TriCounty Community Foundation, past service as a Higginsville City Council member, and Higginsville Chamber of Commerce member. In addition, he volunteers in local conservation organizations, participates in 5K and other races to benefit local groups, is team physician for Lafayette County C-1 schools, and has held various leadership positions in his church. Dr. Pulliam practices at Family Practice Associates of West Central Missouri with clinics in Higginsville and Warrensburg. He resides near Corder, Missouri with his wife, Vickie. They have four children, Gina and her husband Wade, Ashley and her husband Lance, Alison and her

husband Adam, and Camden and his wife Mallory; and seven grandchildren. He has been a member of MAFP since 1983. He is a doctor to all ages, from helping mothers deliver babies to compassionately visiting elderly patients in nursing homes. One patient stated, “his deep and honest concern for me in matters other than my health sets him apart…” Other words used to describe Dr. Pulliam include “skilled, responsible, efficient, compassionate, enthusiastic, and kindhearted.”

Pictured above, L to R, are administrative and nursing personnel at Family Practice Associates spanning more than 30 years: Cindy Shier, Rhonda Dice, DVP, Dr. Pulliam, Colleen Starner, and Brenda Trigg. Pictured left are David Pulliam, DO, and his wife, Vickie (center), with their four children and spouses, grandchildren, and his parents. 18 Missouri Family Physician July - September 2014

Membership Anniversaries MAFP


to all members celebrating a milestone anniversary in 2014. Thank you for your continued support of Family Medicine, your fellow physicians, and your patients. •60 Years• Ervin H. Dorsch, MD, FAAFP (Independence) Leroy J. Miller, MD, FAAFP (Columbia) Thomas A. Nicholas, MD, FAAFP (Lees Summit)

•50 Years• Jacob M. Gandlmayr, MD, FAAFP (St. Louis) Bedford F. Knipschild, MD, FAAFP (Marshall) Joe A. Wall, MD, FAAFP (Houston) Paul A. Williams, MD, FAAFP (Lees Summit)

•45 Years• Donna Drees, MD, FAAFP (Dallas, TX) Sammy L. Farrell, MD, FAAFP (Washington) Robert L. Magee, MD, FAAFP (El Dorado Springs) Melville T. Moore, MD, FAAFP (Cape Girardeau) Robert R. Pavlu, MD, FAAFP (Carrollton) Charles H. Sincox, MD, FAAFP (Washington)

•40 Years• Robert W. Ayres, MD, FAAFP (Lawrence, KS) Thomas A. Johnson, MD, FAAFP (Chesterfield) Robert H. Laatsch, MD, FAAFP (Poplar Bluff) Jerry L. Meyer, MD (Concordia) Seoung Eun Rhee, MD, FAAFP (St. Louis) Lawrence S. Shields, MD, FAAFP (Springfield)

•35 Years• Jeffery L. Belden, MD, FAAFP (Columbia) David C. Campbell, MD, FAAFP (St. Louis) Dwight A. Cashier, MD (Platte City) Christopher Fletcher, MD, FAAFP (Hollister) John E. Goff, MD, FAAFP (Joplin) Dennis M. Handley, MD, FAAFP (Boonville) Larry E. Legler, MD, FAAFP (Independence) Charles A. Nester, Jr., MD, FAAFP (Webster Groves) Natu Bhagabhai Patel, MD, FAAFP (Wilmette, IL) Bruce E. Preston, MD, FAAFP (West Plains) George Prica, MD (Columbia) Kevin B. Smith, MD (Chesterfield) Gary N. Thomsen, MD, FAAFP (Osage Beach) William H. Winkler, MD, FAAFP (Villa Ridge) Robert A. Zink, MD, FAAFP (St. Louis)

•30 Years• Phillip V. Asaro, MD (St. Peters) Kevin D. Boatright, MD (Farmington) Clifford M. Costley, MD, FAAFP (Monett)

•30 Years•

•25 Years•

Peter G. Danis, MD, FAAFP (St. Louis) Edward DuMontier, MD (Farmington) William W. Fish, MD, FAAFP (Liberty) Robert L. Frederickson, MD (Sedalia) Terry E. Hall, MD, FAAFP (Bethany) Randal L. Hamric, MD, FAAFP (Springfield) Deborah A. Herrmann, MD (Marshall) William E. Hines, MD, FAAFP (Florissant) Michael K. Houser, MD (St. Charles) Mark T. Houston, MD, FAAFP (Villa Ridge) Stanley G. Jones, Jr., MD, FAAFP (Sikeston) Martin A. Kanne, MD (Kansas City) Glen R. Kirkpatrick, MD (Parkville) Michael L. LeFevre, MD (Columbia) James P. Lukavsky, MD, FAAFP (Branson) John D. Owen, MD, FAAFP (Liberty) Howard A. Pickett, MD, FAAFP (Excelsior Springs) Paul J. Pierron, DO, FAAFP (Kansas City) Robert W. Power, MD, FAAFP (Jefferson City) Ann Schumacher, MD (Belgrade) John O. Stanley, MD (Kansas City) Michael G. Steenbergen, MD (Jefferson City) Vernon C. Tegtmeyer, MD (Lebanon) James D. Turner, MD, FAAFP (Washington) Christian Wessling, MD (St. Louis) Kenneth G. Weston, MD (Columbia) Thomas L. Wilkins, MD (Kansas City) Stanley J. Wilson, MD, FAAFP (Sedalia) Craig A. Wymore, MD, FAAFP (Leawood, KS) Steven C. Zweig, MD (Columbia)

Marcos A. Iglesias, MD, MMM, FAAFP (Valley Park) Brenda G. Izen, MD (Wildwood) James E. Jones, DO (St. Peters) Christopher L. Kafka, DO (Parkville) Nina M. Kiekhaefer, MD (Jefferson City) Katherine A. Lear, MD (Springfield) Mark A. Lichtenfeld, MD, FAAFP (Chesterfield) Stephanie C. Long, MD (Warrensburg) John V. Mackel, MD, FAAFP (Cape Girardeau) John M. McCormack, MD (West Plains) David A. Miller, MD, FAAFP (Wildwood) Michael C. Misko, MD, CPE, , FAAFP (Centerview) Christopher B. Normile, MD (St. Charles) Jolene A. Ostwinkle, DO (Lebanon) James E. Palen, MD, FAAFP (Cape Girardeau) Donald E. Philgreen, MD, FAAFP (Kansas City) Kenneth D. Phillips, MD (Cape Girardeau) Leslie A. Robins, DO, FAAFP (St. Charles) Beth E. Rosemergey, DO, FAAFP (Lees Summit) Jacqueline M. Ruplinger, MD (Columbia) Manuel A. Salinas, MD (Springfield) John D. Salmon, MD (Branson) Robert Schaaf, MD, FAAFP (S.t Joseph) Larry M. Slaughter, MD, FAAFP (Columbia) Jeffrey A. Suzewits, DO, MPH, FAAFP (Kansas City) John T. Symonds, DO (Maryville) Steve Taylor, MD (Mexico) John C. Wendt, MD (Sedalia) Russell K. L. Won, MD (St. Louis) Evelyn W. Young, MD (De Soto)

•25 Years• John D. Barth, DO (Holt) Lisa C. Burns, MD (Town And Country) Samuel A. Crow, DO, FAAFP (Branson) Steven C. Eldenburg, DO, FAAFP (Sedalia) Ronald A. Evans, MD (Bolivar) Anne B. Fitzsimmons, MD (Columbia) Michelle R. Franey, MD (Grandview) Timothy A. Fursa, MD (Springfield) Gregory R. Goodwin, DO, FAAFP (Rogersville) Charles S. Halbeck, DO (St. Louis) Thomas K. Hamilton, DO (Joplin) Tammy K. Hart, MD (Princeton) Jimmy D. Heath, MD (East Prairie) Elton W. Hoerning, MD (Mountain Grove) Laura E. Holmes, MD, FAAFP (Cape Girardeau)

Pictured above, William Fish, MD (right) presents Bruce Preston, MD (left) with a certificate commemorating his 35 years of membership with the Missouri Academy. Other physicians recognized during the ceremony included Jeff Suzewits, DO, for 25 years and William Fish, MD, for 30 years.

Missouri Family Physician July - September 2014


MAFP Members in the News

Members in the News Congratulations Rachel Herdes and Andrew Berry! AAFP chose your poster “Small Bowel Obstruction: An Atypical Presentation of Metastatic Primary Lung Adenocarcinoma” Andrew Berry as part of the 2014 National Conference Poster Competition. Posters were displayed in the Exposition Hall on Thursday through Saturday, August 7-9 (in conjunction with NCFMRS in Kansas City). Outstanding poster Rachel Herdes presentations will be recognized and the top resident and student will win a trip to present their poster at the 2014 Assembly in Washington, DC.

Jeffrey Suzewits, DO, MPH, FAAFP, FAODME, has accepted a new position as the Central Illinois Divisional Chief Medical Informatics Officer (CMIO) for the Hospital Sisters Health System. Jeffrey Suzewits, DO He will work with doctors and their Electronic Health Records (EHR) systems at five hospitals in Central Illinois. He will be located at St. John's Hospital in Springfield, Illinois, their flagship hospital. Dr. Suzewits leaves his position as Associate Dean of Clinical Education Professor of Family & Community Medicine, Kansas City University of Medicine & Biosciences.

Logan Banks, DO, FAAFP, became a Fellow of the AAFP in May. The Degree of Fellow recognizes AAFP members who have distinguished themselves among their colleagues, as well as in their comLogan Banks, DO munities, by their service to family medicine, by their advancement of health care to the American people and by their professional development through medical education and research. Fellows of the AAFP are recognized as Champions of Family Medicine. They are the physicians who make family medicine the premier specialty in service to their community and profession. From a personal perspective, being a Fellow signifies not only 'tenure' but one's additional work in your community, within organized medicine, within teaching, and a greater commitment to continuing professional development and/or research. For more information about becoming a Fellow, please visit:”

Program of Excellence The American Academy of Family Physicians has named 18 medical school Family Medicine Interest Groups as the 2014 Program of Excellence Award winners for their outstanding activities in generating interest in family medicine.

Award winners were honored during an August 8 ceremony at the AAFP National Conference of Family Medicine Residents and Medical Students in Kansas City. Saint Louis University School of Medicine Family Medicine Interest Group was one of the winners of the overall 2014 POE Award Recipients

Dr. Joseph Novinger and Christine Wilson

Christine Wilson was the recipient of the Top Medical Student in Family Medicine at A.T. Still University-Kirksville College of Osteopathic Medicine. The Family Health Foundation of Missouri Award was presented at their Awards Banquet. Each year the recipient is surprised to receive such excellent recognition.

20 Missouri Family Physician July - September 2014

Mark Your Calendar MAFP Advocacy Day February 24, 2015 Jefferson City

Members in the News MAFP Top Ten Award Recipient University of Missouri - Columbia School of Medicine The University of Missouri-Columbia School of Medicine was recently recognized by the American Academy of Family Physicians (AAFP) for 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. The faculty, staff and residents are to be commended for their achievements in graduating students into Family Medicine. Their support of this critical endeavor of addressing the primary care workforce pipeline needs of our country was recognized in May.

University of Missouri - Columbia School of Medicine Recipients of the AAFP Top Ten Award

FMIG Funding Available Family Medicine Interest Groups (FMIGs) can receive $600 for the 20142015 academic year from the AAFP and AAFP Foundation. The FMIG Funding Initiative provides much-needed assistance to FMIGs working to build student interest in family medicine on college campuses across the country. Eligibility requirements for an FMIG to qualify are available on the AAFP website. Groups are free to use the funds for any purpose they choose (e.g., meals for meetings, funds for students to attend regional and national meetings, or supplies for fundraisers). Some level of chapter involvement is required, and additional chapter involvement to help medical schools put on quality programming is encouraged. Chapter involvement might include the following: •

Collect and distribute the funds (AAFP can write checks to chapters instead of the school). • Bring guest physicians to the schools to speak on Family Medicine. • Ensure a school completes the required application and materials by the December 5, 2014 deadline. Contact Sam Carlson at to find out where specific schools are in the process, or to contact FMIG Faculty Advisors and student leaders. Missouri Family Physician July - September 2014


MAFP AFC Schedule of Events Big Cedar Lodge Ridgedale, Missouri Friday, November 7, 2014

Register online today! Early bird registration ends October 6.

7:00 – 11:30 am Exhibit Hall Open (Grandview Ballrooms A & B)

9:00 – 10:00 am 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to JNC 8 Michael LeFevre, MD, MSPH (Columbia, MO)

All lectures will be held in Grandview Ballrooms C&D

10:00 – 10:45 am Refreshment Break with Exhibitors

7:55 am Welcome and Introductions (Grandview Ballrooms C & D)

10:45 am – 12:15 pm The Emerging Role of the Kidney and SGLT2 Inhibition in Patients with Type 2 Diabetes Silvio E. Inzucchi, MD (New Haven, CT)

7:00 – 8:00 am Registration & Breakfast Buffet with Exhibitors

8:00 – 9:00 am Hypertension in Children Mark Suenram, MD (Kansas City, MO) 9:00 – 10:00 am Epigenetics and Migraine Pathophysiology Roger Cady, MD (Springfield, MO) 10:00 – 10:45 am Refreshment Break with Exhibitors 10:45 am – 11:45 pm The Evidence on Treating Hyperlipidemia James Stevermer, MD, MPSH (Columbia, MO)

1:45 – 2:45 pm AAFP Chapter Lecture Series: Barriers to Adult Immunizations This activity is funded by an educational grant to the AAFP from Merck. David Glenn Weismiller, ScM, MD, FAAFP (Greenville, NC)

2:15 – 4:15 pm ER/LA Opioid REMS: Achieving Safe Use While Improving Patient Care Katherine E. Galluzzi, DO, CMD, FACOFP (Philadelphia, PA)

Saturday, November 8, 2014

7:00 – 8:00 am Registration & Breakfast with Exhibitors 7:00 – 11:30 am Exhibit Hall Open (Grandview Ballrooms A & B) All lectures will be held in Grandview Ballrooms C&D 8:00 – 9:00 am Healing the Healer Charles Sincox, MD (Washington, MO)

4:45 – 6:45 pm MAFP Board Meeting

Sunday, November 9, 2014 8:00 am – 2:30 pm SAM Working Group: Pain Management (Grandview Ballroom A) James Stevermer, MD, MSPH & Lucas Buffaloe, MD Additional fee applies.

Job Opportunity

1:00 – 2:00 pm AAFP Chapter Lecture Series: Adolescent Immunizations – Barriers that Exist This activity is funded by an educational grant to the AAFP from Merck. Speaker TBD 2:00 – 2:15 pm Break

3:45 – 4:45 pm MAFP Commission Meetings (Advocacy, Education and Member Services)

12:15 – 1:45 pm Management of Patients with Chronic Hepatitis C: The Route to Safe and Effective Care Kenneth Lichtenstein, MD (Denver, CO) Box Lunch Included

11:45 pm – 1:00 pm Lung Cancer Screening: USPSTF Recommendation Michael LeFevre, MD, MSPH (Columbia, MO) Box Lunch Included

2:45 – 3:45 pm Improving the Identification and Management of Osteoporosis: A Curriculum for the PCP Speaker TBD

FACULTY CLINICIAN - FAMILY MEDICINE 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 commitment to training future family physicians is sought to join an innovative medical home family medicine practice at Saint Louis University. This faculty position includes outpatient family medicine practice, teaching in the medical school and residency programs, and participation in opportunities for scholarship. This assignment will include clinical sessions at our SLUCare Family Medicine practice at The University Tower in Richmond Heights, as well as outpatient oncall and rotations on the inpatient service at St. Mary’s Hospital. Application must be made online at; application must include a cover letter and curriculum vita. In addition to applying online, applicants may send their curriculum vitae with an introductory letter describing their past experience and three letters of recommendation to F. David Schneider, MD. MSPH, Professor and Chair, Department of Family and Community Medicine, 1402 S. Grand Blvd., St. Louis, MO 63104, or via e-mail to 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.

22 Missouri Family Physician July - September 2014

Externship Essay MAFP

Externship Essay by Mitchell Elting

From knee and shoulder injections, skin lesion removals, wound packing, suturing, and many other procedures, I was able to practice skills at a level that most students do not get the opportunity to do until their intern year of residency. I also spent a week in the OB department and received exposure to the Family Medicine aspects of the field. I observed multiple circumcisions, cesarean section deliveries, and newborn exams alongside the residents and faculty. Furthermore, I participated in an OB outreach clinic in Harrisonville, Missouri and assisted with prenatal and infant care for families with limited funds and access to affordable care. I loved being a part of the process through interacting with the patients, listening to fetal heart sounds, and

seeing some familiar faces each week and observing their progression. Regardless of the departmental setting I was scheduled for on a given day, the 2014 Summer Externship allowed me to practice clinical skills and embrace the patient/ physician relationships that originally lured me to pursue a career in Family Medicine. I want to thank the MAFP for giving me the chance to participate in this amazing program. I would also like to give a big thank you to the Research Family Medicine Residency Program for making me feel welcome and providing an outstanding environment for learning and professional growth. The program has further cemented my drive to become a great Family Physician and to strive for providing exceptional care to my future patients.

Last month, I had the wonderful opportunity to gain hands-on experience in the field of Family Medicine by working alongside residents and faculty at the Research Family Medicine Residency Program in Kansas City, Missouri. During my four weeks, I gained a wide range of exposure to multiple areas of Family Medicine. The variety of outpatient, OB, inpatient, and outreach clinical exposure I received gave me a well-rounded look at what Family Medicine has to offer as a future career. The faculty and residents were very encouraging, always welcoming of questions, and willing to provide constructive feedback that helped me to improve my clinical skills and knowledge. The support was particularly exceptional during my time in the outpatient clinic setting. Each day I was given the opportunity to see a full patient list on my own with the goal of Missouri Health Professional Placement Services (MHPPS) is dedicated to rural and recording thorough histories and underserved areas of our great state! We partner with safety-net providers and health care performing physical exams. I systems throughout Missouri to help health care professionals, like yourself, find a would then report to the resident community that best fits your personal and professional needs. Whether it’s a scenic rural or faculty physician to discuss setting, dynamic urban location, or somewhere in between, we are committed to focusing on each patient’s situation and try to your interests and careers that count! formulate treatment plans. During this process, my mentors would not Family Medicine Opportunities only ask about “what” I thought Find Out More: we should do for each patient, but Joni Adamson, Manager of Recruitment - Loan Repayment Options more importantly, “why” I thought 573.636.4222 - Competitive Salary & Comprehensive Benefits the plan was the correct approach. - Available Throughout our Rural & Urban Areas These types of questions helped me - Contact us Today! to improve my thought processes Proud Partners: and information gathering skills beyond first-line thinking. Additionally, the level of hands-on experience I received was unmatched by any clinical experience I have encountered MHPPS is non-profit and located within the MO Primary Care Association so far in my short medical career. Missouri Family Physician July - September 2014


MAFP 2014 Legislative Session Update

Health Care Legislation – 2014 Session of the Missouri General Assembly by Pat Strader, MAFP Legislative & Governmental Consultant The 2014 legislative session ended on Friday, May 16. Approximately 1,900 bills and joint resolutions were introduced this session. Of that number, 190 were truly agreed to and sent to the Governor. However, it’s important to note that many were omnibus bills containing on average 10 to15 different legislative measures. Unfortunately, tort reform repair and Medicaid expansion did not make it through the process. Several positive bills did pass while dozens of bills we opposed did not. Governor Nixon had until July 14th to determine his action on legislation. His choices were to (1) sign the bill into law; (2) veto the bill, or (3) let the bill go into effect without his signature. The Governor has line item veto for appropriations. In all, the Governor vetoed 46 bills and vetoed and/or withheld dollars for various programs included in the FY2015 Budget sent to him by the Legislature. Unfortunately, the general revenue dollars included in HB2011 for continuation of the “enhanced primary care services rate” was line item vetoed by the Governor. Legislation is effective August 28th unless it has a specific operation of law date or an emergency clause which means the bill becomes effective on the date it is signed into law. The Governor’s action is included below for those bills that “passed”. Tort Reform Repair The Missouri House of Representatives passed a tort reform bill that would have reinstated a $350,000 statutory cap on non-economic damages in medical malpractice cases. And again, the Senate failed to pass this bill – or any form of a bill. The gap was too wide between what the medical community could agree to and

what the trial attorneys would accept. They also wanted to reinstate a cost of living adjustment. Other tort reform measures, such as joint and several liability and capping attorney contingency fees, were debated in the Senate but also failed to make it through the process. The Missouri Tort Reform Coalition will continue to meet throughout the summer and fall to support reinstatement of a reasonable cap in the 2015 legislative session. (HB 1173; SB 589) Medicaid Expansion Expansion did not occur this session – but not for lack of trying. Governor Nixon continued to push for expansion to the end of session, but there was too much opposition from the legislature. While a number of bills moved through the process, they were basically transformation and reform measures. Several amendments and substitute bills floated near the end of session included a myriad of ideas from reform to expanding coverage up to 138% by using federal money to help finance private health insurance for low-income adults. The conversations will continue during the interim on this important topic and it will be a top agenda item next session for the Academy. WHAT PASSED Assistant Physicians – “First in the Nation to Adopt Such Licensure” Dr. Keith Frederick sponsored this legislation as a stand-alone bill, adding it to a number of omnibus bills during the last few weeks of session. This proposal was “priority” legislation for Missouri State Medical Association and was also supported by the Missouri Association of Osteopathic Physicians and Surgeons. It allows certain medical school graduates to obtain a temporary assistant physician license in order to enter into a collaborative

24 Missouri Family Physician July - September 2014

practice arrangement with a physician. An assistant physician is defined as any medical school graduate who has passed the prescribed medical examinations and who has not entered into postgraduate residence training. The act prescribes other requirements to be licensed and specifies certain practices an assistant physician cannot perform. The collaborating physician is responsible at all times for the oversight and activities of the assistant physician and accepts responsibility for primary care services rendered by them. Many legislators felt this would allow those individuals who qualify for the license to enhance their skills, while increasing access to care for patients in rural areas of the state. MAFP neither supported nor opposed the legislation but was not shy in sharing our concerns about the bill. Since Missouri is the first state in the nation to adopt this newly-created health care professional license, groups and individuals throughout the country are weighing in on the upside and downside of this idea. While the bill was signed into law as a part of two large omnibus bills, the Governor commented in his signature letters as follows: “Because this new licensure for “assistant physicians” would circumvent well-established and long-standing physician licensing procedures, additional safeguards are necessary to ensure that individuals who have failed to complete residency or failed to obtain physician licensure for competency or other reasons are not allowed to practice as assistant physicians. Ensuring that all Missourians have access to adequate health care is a laudable goal, but it is equally important that such measures do not place citizens’ health in jeopardy….” The promulgation of rules on this legislation will be long and arduous. It is important to note that the legislation calls for input in the development of rules by the deans of the medical schools and primary care residency

2014 Legislative Session Update MAFP program directors in the state. MAFP will have ample opportunity to participate in and comment on the rules and regulations. (SB716; SB754) Signed by the Governor Show-Me Echo Program This bill establishes the Echo Program (Effective Community Health Outcomes) designed to link primary care providers to specialists, through consultation and education, to provide the latest evidencebased treatment for patients. Under the bill, the University of Missouri would manage the program in collaboration with the Department of Health and Senior Services. The program is patterned after one from the state of New Mexico which is credited with helping New Mexico rural physicians treat Hepatitis C patients. While the legislation was signed into law as it was contained in two omnibus health care bills, the Governor vetoed the funding for the program ($1.5 million within HB2003). The coalition that is pushing this legislation is looking for alternative funding mechanisms. While this is one of those bills that appears helpful on the surface, as they say, the “devil is in the details”. We have several unanswered questions regarding workings of the program and will participate actively in the rule promulgation process. (SB716; SB754) Signed by the Governor Tanning Beds This bill requires the parent or guardian of a person under17 years of age using a tanning device in a tanning facility, to annually appear in person and sign a parental consent form. The bill sets monetary violations for tanning facilities that violate provisions of the act. (HB1411) Signed by the Governor Pharmacists Provided Vaccines This legislation (originally filed as HB 1683) adds hepatitis A, hepatitis B, diphtheria, tetanus and pertussis as immunizations a pharmacist may administer to the current ones in statute -- influenza, pneumonia, shingles and meningitis. They must be provided by written protocol authorized by a physician. The language is confusing as it still

contains the wording where these vaccines can be provided by written protocol authorized by a physician (a blanket protocol) by rule OR the administration of those vaccines by written protocol authorized by a physician for a specific patient. It also includes language within the statute that requires pharmacists to receive additional training for the administration of vaccines and requires them to provide specified information to the patient’s primary health care provider within 14 days of administering a vaccine. (SB808; SB716; SB754) Signed by the Governor APRN Restraints This bill allows APRNS working in a collaborative practice agreement in mental health facilities to order patient restraints when deemed necessary. Orders must be reviewed by the collaborating physician within 24 hours. The legislation contains specific provisions for restraints for persons under age 18 and prohibits restraints for persons that are developmentally disabled. (HB1779) Signed by the Governor Prior Authorization This bill requires insurance carriers to make a determination of benefits with 36 hours of receiving all necessary information. (SB716) Signed by the Governor E-Cigarettes This legislation created new definitions for vapor and alternative nicotine products. While the sponsor’s intent was to prohibit sales of e-cigarettes and alternative nicotine products to youths under the age of 18, the downside is the newly-created definitions of these products are distinctly separate from “tobacco products” which would limit the Legislature’s ability to tax or regulate them in the future. The Academy sent a letter to Governor Nixon expressing our concerns with the legislation. (SB841) Vetoed by the Governor Firearms This legislation would have allowed Missouri school districts to designate teachers or administrators as “school protection officers” who would have been authorized to carry concealed firearms

within those districts. It also contained language that would have restricted a physician’s ability to document patient gun ownership in medical records or report issues of concern. Further, it prohibited health care professionals from using an electronic medical record program that requires the entry of data regarding firearms. (SB656) Vetoed by the Governor CBD Oil This bill allows the use of hemp extract for the treatment of intractable epilepsy and creates licensing and registration procedures for the use, manufacture, and distribution of hemp. It also authorizes the Department to promulgate rules to authorize clinical trials involving the extract. The bill contains an emergency clause. (HB2238) Signed by the Governor Joint Committee on Eating Disorders This act establishes a Joint Committee on Eating Disorders to review issues pertaining to the regulation of insurance and other matters impacting the lives of those diagnosed with an eating disorder. By December 31, 2014, the committee shall provide a report to the members of the General Assembly and the Governor. (SB754) Signed by the Governor Diabetes Care & Control This bill requires MO HealthNet and the Department of Health and Senior Services to collaborate to coordinate goals and benchmarks in each individual agency’s plans to reduce the incidence of diabetes, improve diabetes care, and control complications associated with diabetes. A report must be submitted to the General Assembly by January 1 of each odd-numbered year. (SB754; SB716) Signed by the Governor Meningococcal Vaccine Under this act, each student attending a public institution of higher education who lives in on-campus housing must receive the meningococcal vaccine unless he or she has a medical or religious exemption. The Department of Higher Education must oversee, supervise, and enforce this requirement and may promulgate rules.

Missouri Family Physician July - September 2014


MAFP 2014 Legislative Session Update The Department of Higher Education may consult with the Department of Health and Senior Services. (SB716; SB754) Signed by the Governor Influenza Vaccinations This bill requires that each year between October 1 and March 1, hospitals shall offer prior to discharge immunizations against influenza virus to all inpatients 65 years of age or older unless contraindicated for such patient so long as there is approval of the attending physician. (SB754; SB716) Signed by the Governor Physician Assistant as MO HealthNet Provider This provision allows for a physician assistant to enroll with the Department of Social Services as a MO HealthNet provider while acting under a supervision agreement between the physician and the physician assistant (SB716). Signed by the Governor Dense Breast Tissue This measure requires information on further testing to be given to patients whose mammography reveals dense breast tissue. (SB639; SB 754) Signed by the Governor Class B Pharmacies This bill allows hospital medical staffs to enter into medication therapy agreements with class B pharmacies, rather than each individual physician who practices at the hospital. Individual physicians will maintain the ability to override the medical staff’s therapy protocol for their patients. (SB716) Signed by the Governor Investigational Drugs This bill (also referred to as the “right to try”) allows physicians to prescribe investigational drugs to terminally ill patients and provides for immunity. (HB1685) Signed by the Governor Oral Chemotherapy This measure requires health benefit plans to establish equal out of pocket costs for covered oral and intravenously administered chemotherapy medications.

(SB668) Signed by the Governor Health Insurance Navigators This act requires that an applicant for a navigator license must take an exam created by the Department of Insurance and submit to a criminal background check. While federal law does not require criminal background checks for navigators, states can set their own rules. In his veto message the Governor cited a drafting error where the wrong federal statute was referenced in the legislation. (SB508) Vetoed by the Governor SCHIP Program Currently, the State Children's Health Insurance Program (SCHIP) defines uninsured children as an individual up to 19 years of age who meets specified criteria and whose parent or guardian has not had access to affordable coverage for their children for six months prior to application for SCHIP. This act removes the requirement that they be uninsured for six months. The act also changes the requirements of a parent of such child eligible for SCHIP by removing the requirement that the parent or guardian demonstrate annually that their total net worth does not exceed $250,000 in total value. (SB754) Signed by the Governor Umbilical Cord Blood Bank Beginning July 1, 2015, this act requires the Department of Health and Senior Services to transport collected, donated umbilical cord blood samples to a nonprofit umbilical cord blood bank located in St. Louis City in existence as of the effective date of the act. The collection sites shall only be those facilities designated and trained by the blood bank in the collection and handling of umbilical cord blood specimens. (SB 754; SB716) Signed by the Governor Breast Milk Donor This act requires the Department of Social Services to reimburse hospitals under the MO HealthNet program for donor human milk provided to critically ill infants less than three months of age in the neonatal intensive care unit, if the physician orders

26 Missouri Family Physician July - September 2014

the milk and the Department determines it is medically necessary. Such donor milk shall be obtained from a donor bank that meets the Department's guidelines. (SB754) Signed by the Governor Voluntary Registry/Disasters and Emergencies This bill allows counties to create a voluntary registry of persons with healthrelated ailments to assist them in the case of an emergency or disaster. (SB 767; HB1426) Signed by the Governor State Agency Website Information This measure requires state agencies to post proposed rules, summaries and fiscal notes on their websites. (SB504) Signed by the Governor Relative Caregivers This act modifies provisions relating to educational and medical consent provided for minor children by relative caregivers. (SB532) Signed by the Governor LEGISLATION THAT FAILED TO PASS Clinical Lab This bill would have established the licensure of clinical lab personnel, including phlebotomists and lab technicians. Our concern with this bill is that it could be detrimental to rural physician offices that cannot afford to hire or cannot find a licensed technician for their offices. (SB569) Drug Monitoring (PDMP) This legislation would have implemented a prescription drug monitoring program for Missouri. The statewide database would provide physicians with important information regarding a patient’s current prescriptions. Accessing the database would be optional for the physician. At this point in time, Missouri is the only state that has not adopted a PDMP; however, several states that have adopted one have yet to fund it. There will be a concerted effort to pass this legislation in 2015. (HB1133) Perinatal Care This bill would have created the Perinatal

2014 Legislative Session Update MAFP Advisory Council responsible for establishing standards for all levels of hospital perinatal care, including regional perinatal centers and birthing centers. It contained many provisions that raised “red flags” with legislators and physicians. For instance, the legislation refers to “community providers” although the term is not defined in the bill. (HB1898) APRNS Significant time was spent this session in tracking the many bills relating to nurses. Near the end of session, the nurses attempted to amend various amendments onto moving omnibus bills. None of the introduced bills or last minute amendments passed. • Would have created a new licensure category of “APRN”, added a long list of new scope of practice provisions, and allowed APRNs to administer medication therapy. Specified APRNS were responsible to their profession, the Board of Nursing and their patients, but no mention of responsibility to their collaborating physician. This bill would also have made rules that were previously jointly promulgated by the Board of Healing Arts and Board of Nursing “null and void” except for the rules relating to controlled substances. (HB1491; SB659) • Would have gutted the language regarding collaborative practice agreements and eliminated “proximity rule” in statute in favor of “effective electronic communication”. This bill also contained the language voiding previous jointly-promulgated rules. (HB 1481; SB 700) Midwifery Two bills were introduced this session relating to lay midwives. Both bills had hearings but did not progress beyond the committee level: • Licensure – Created a six-member Board of Professional Midwives under the Division of Professional

Registration and required applicants to provide evidence of current certification as a certified professional midwife by the North American Registry of Midwives. The bill would not have had any oversight of lay midwives who are not certified by NARM. (HB1361); • Midwife Insurance – Would have required lay midwives providing homebirth services to carry $1 million in liability insurance and provide clients proof of such insurance. (HB2189) Immunization Registry Two bills were filed that would have required all immunization providers to submit vaccination records of adults and children to the Missouri Immunization Registry. The bill contained language authorizing sanctions against immunization providers or other certified users for violations of the act and made them subject to civil actions or penalties for damages resulting from such violations. (HB 1445; SB817) Clean Indoor Air Legislation introduced in the House would have established a statewide smoke free law aimed at protecting Missourians from secondhand smoke in the workplace. (HB1716) Chiropractors/ MO HealthNet Reimbursement While a separate bill was not filed, amendments addressing Medicaid expansion/ reform included provisions to cover chiropractic

services under MO HealthNet. Motorcycle Helmet Repeal This legislation made it through the House but stalled in the Senate. It would have repealed Missouri’s motorcycle helmet law for operators and riders. (HB 1655) AEDs Legislation was filed that would have inadvertently removed the civil liability exemption in statute for a “licensed physician who reviews and approves the clinical protocol” for automated external defibrillators. (HB1114) Texting While Driving Many bills were filed that would have prohibited texting while driving for all drivers, regardless of age. Conscience Rights of Individuals This act specified that anyone providing medical services could not be required to perform or participate in activities that violate his or her conscience or principles. (HB1430)

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Missouri Family Physician July - September 2014



28 Missouri Family Physician July - September 2014


NCSC Experience by Wael Mourad, MD Last month, I was pleased to have the good fortune of attending the AAFP's NCSC for the first time. Not only was it was an opportunity to acquire a fresh perspective and realization of what the AAFP means to me, it was also a platform to immediately participate in the legislative process that guides the focus of our professional body on future priorities. While representing the Show Me State, I was in turn shown what a fabulous professional resource we have in the MAFP. My only regret is that my weekend call schedule kept me from attending the conference in its entirety! Despite the demands of clinical duties however, my window of opportunity was just enough to serve on the Education Committee, meet my Missourian colleagues and members of the delegation, and take in the multiple personal testimonials from fellow Family Physicians at all stages in their careers on how the AAFP and NCSC paved avenues for professional development, advancement and achievement. When I come back to my residents and colleagues at the UMKC Family Medicine Residency Program, I can tell them how wonderfully encouraging the strong and distinguished leadership of the AAFP was in my development as a provider and person; how organized and structured the AAFP is, and the approach of its constituents; how the AAFP and NCSC have a history of progress spanning several decades as they usher new generations of Family Physicians to an exciting and uncertain future; and how it was yet another reminder that the concerns of the AAFP are very much society's concerns. I am certain that Drs. Ross and Garcia, also representatives of the great state of Missouri whom I met, would agree that the NCSC event met our every expectation, and that the AAFP and MAFP are invaluable resources not only to ourselves as practitioners, but to the communities and families that we serve. I look forward to 2015.

ASK your patients if they use tobacco. ACT to help them quit. Tobacco cessation resources available at - Quitline Referral Cards - Posters QUIT NOW - Stop Smoking Guide Ask us how - Patient Education Materials - Lapel Pins - EHR Guide - Pharmacologic Product QUIT-NOW Guide - Online Training - Group Visits Guide - Coding for Payment “ Patients who have been Be tobacco-free


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Many materials available in both English and Spanish!

advised to quit smoking by their doctors have a 66 percent higher rate of success.” U.S. Surgeon General Regina Benjamin, MD, MBA

Wael S. Mourad, MD Assistant Professor Advanced Obstetrics Fellowship Faculty University of Missouri Kansas City School of Medicine Truman Medical Center Lakewood Department of Community and Family Medicine MAFP Member since 2008

Missouri Family Physician July - September 2014


MAFP 2014 Annual Scientific Assembly Exhibitors

Thank you

>> 2014 ASA Exhibitors

The MAFP would like to recognize and thank the organizations who supported and participated in the 66th Annual Scientific Assembly in June. Join us in expressing our appreciation to the following:

Anthem Blue Cross/Blue Shield

Missouri Army National Guard

Direct Primary Care Clinics

Missouri Professionals Mutual (MPM)

Eli Lilly

MO Health Professional Placement Services

Freeman Health System

PDS Cortex

Health Diagnostic Laboratory, Inc.



Sanofi Pasteur

Mercy Clinic

U.S. Army Healthcare

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30 Missouri Family Physician July - September 2014

2014 Tar Wars Poster Contest Winner MAFP

Today more than 3,500 children will try their first cigarette.

Stop kids from starting. Volunteer to be a Tar Wars presenter.

Supported in part by a grant from the American Academy of Family Physicians Foundation.

Missouri Tar Wars Poster Contest Winner TW hlf horiz.10_v2.indd 1

Amanda Hearn, pictured right, from Wellington-Napoleon Elementary School in Wellington, Missouri, was the 2014 first place winner of the Missouri Academy's Tar Wars poster contest. A total of 30 posters were submitted. Amanda also placed 9th out of 35 posters overall at the annual Tar Wars National Conference held July 21-22 in Washington, DC. 1st Place: Amanda Hearn Wellington-Napoleon Elementary School, Wellington, MO 2nd Place (TIE): Cheyenne Richardson Craig R-3 School, Craig, MO

9/3/10 11:58 AM

2nd Place (TIE): Aracely Alvarado-Perez Santa Fe Elementary School, Waverly, MO 4th Place: Trevor Livengood Craig R-3 School, Craig, MO 5th Place: Lynden Prussman South Holt R-1 School, Oregon, MO To view all of these posters, visit the new MAFP website and click on the Foundation/Tar Wars Program tabs!

Missouri Family Physician July - September 2014


U stability N predictability P reliability A believability R sustainability A L trustability L respectability E accountability L availability E D professional liability Timothy H. Trout Managing Director

287 North Lindbergh Blvd. Saint Louis, Missouri 63141

314 587 8000 OFFICE 314 587 8001 FAX /

Mafp magazine jul sep 2014 final  
Mafp magazine jul sep 2014 final