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Official Publication of the Missouri Academy of Family Physicians

Family Physician

October-December 2013 Volume 32, Issue 4

2013 Tar Wars Poster Contest Winner, Monique Arroyo pg. 15

AAFP Congress of Delegates Report pg. 4

FM Residency Program Composites pg. 22-27

Contents MAFP

Mark your Executive Commission Board Chair - Kate Lichtenberg, DO, MPH (Kirkwood) President - Bill Fish, MD (Liberty) President-elect - Daniel Purdom, MD (Kansas City) Vice President - Peter Koopman, MD (Columbia) Secretary/Treasurer - Tracy Godfrey, MD (Joplin) 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: Vacant District 4 Director: Vacant Alternate: Vacant District 5 Director: James Stevermer, MD, MSPH Director: Vacant Alternate: Vacant District 6 Director: Jamie Ulbrich, MD Alternate: Vacant District 7 Director: Kathleen Eubanks-Meng, DO Director: George Harris, MD, MS Alternate: Vacant District 8 Director: Mark Woods, MD Director: John Paulson, DO, PhD Alternate: Vacant District 9 Director: Vacant 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) AAFP Delegates Larry Rues, MD Darryl Nelson, MD Bruce Preston, MD (Alternate) Keith Ratcliff, MD (Alternate) MAFP Staff Education & Finance Director - Nancy Griffin Managing Editor/Member Services - Laurie Bernskoetter Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p (573) 635-0830

f (573) 635-0148


MAFP 21st Annual Fall Conference & SAM Working Group See pg. 12 November 8-10, 2013 Big Cedar Lodge, Ridgedale, MO

AAFP Annual Leadership Forum (ALF) & NCSC May 1-3, 2014 Sheraton KC Hotel at Crown Center Kansas City, MO

MAFP Annual Advocacy Day & Board Meeting February 25, 2014 State Capitol, Jefferson City, MO

MAFP 66th Annual Scientific Assembly June 6-8, 2014 Lodge of Four Seasons, Lake Ozark, MO

AAFP Family Medicine Congressional Conference April 7-8, 2014 Renaissance Washington DC Downtown Hotel Washington, DC

MAFP 22nd Annual Fall Conference & SAM Working Group November 7-9, 2014 Big Cedar Lodge, Ridgedale, MO

Save the date

Advocacy Day

February 25, 2014 State Capitol Jefferson City

Inside this issue 4

President's Perspective


Congress of Delegates Report


Help Desk Answers


Externship Experience

William Fish, MD, FAAFP

18 Historic Growth Rates Vary Widely Across the Primary Care Physician Disciplines American Family Physician, Oct 2013

20 Help Desk Answers

Resident Case Studies

Resident Case Studies

22 Residency Programs

Jenny Eichhorn Michele Wong Kevin Gray

10 Resident Grand Rounds Jason Goergen, DO Kavitha Arabindoo, MD

12 Annual Fall Conference

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United States Army


Missouri Health Professional Placement Services

12 Nominate 2014 Family Physician of 13 the Year 17 14 Members in the News 15 Missouri Tar Wars Program 19 Receives Recognition 16 Resident Grand Rounds Jay Patel, DO Jennifer Kelley, MD Jon Welsch, MD

United Allergy Services Physicians Professional Indemnity Association (PPIA) National Dairy Council

21 ProAssurance 25 HEALTHeCAREERS 28 Missouri Professionals Mutual (MPM)

Missouri Family Physician October - December 2013


MAFP President's Perspective

William Fish, MD, FAAFP 2013-2014 MAFP President


e are in a time of rapid change for family medicine, and many of those changes have resulted in increased costs as we transition our practices to the medical home model, convert to electronic medical records and prepare for ICD-10 and edicts of the Affordable Care Act. With our increased costs, our membership appropriately looks at areas where we can reduce those costs and gain the greatest value for our dollar. Knowing family physicians expect value, I reviewed with our national academy where the MAFP’s annual dues stand in relation to other state chapters. Your MAFP dues are now at $275 per year and are the lowest of any state polled by the AAFP. Our dues are approximately $100 less than Colorado, Indiana, Georgia and Iowa — chapters with similar membership numbers to our own. I feel we can be satisfied that our state academy brings us value and is a critical expense for our membership. We must have a seat at the table when health care policy is determined at the state level, and our voice must be heard within the national organization as they address U.S. health policy. Our staff, board, and members serve on numerous state health policy committees, and our board and members testify regularly, with great success, in the state capitol on legislative issues. The MAFP regularly produces leaders at the national level, with a former president of our academy, Mike Munger, MD, just being elected to the AAFP board. Also, former MAFP president Julie Wood, MD, served on the board and now serving as AAFP Vice President for Health of the Public and Interprofessional Activities. David Barbe, MD, serves on the AMA’s board of trustees and Rob Schaaf, MD, is a state Senator. Former MAFP board members have served on the Board of Healing Arts and other appointed health–related positions within the state. Our academy maintains an outstanding staff that produce quality continuing education meetings and this magazine. We also employ a quality lobbyist well known in Jefferson City. With tort reform, scope of practice, reimbursement and administrative burdens as continuing concerns, we need representation more than ever. In summary, I believe our academy is serving us well and providing good value, and we can feel good knowing our voice is being heard in Jefferson City and Washington D.C. 4

Missouri Family Physician October - December 2013

AAFP Congress of Delegates San Diego, California September 23-26, 2013

Following is a summary of what your Missouri delegates believe to be the most important issues discussed by the Congress of Delegates this year. As always, the thoughtful level of the debate on very controversial – and sometimes emotional – issues was always professional and respectful of differences in opinion. Nowhere was this more apparent than in the recurring debate on the "same-sex marriage" issue. While the debate was long and hard, the Congress did not reverse their 2012 acceptance of same-sex unions and use the term "marriage" to include a union between two same-gender individuals. This issue has been debated for several years, and it has become more clear that the health of those in same-sex unions (including children) could be harmed if it was not considered a legal marriage. Some argued this issue is not the business of the Academy. Others pointed out that the AAFP has long advocated for health promotion and against discrimination in health care access. With regard to the term "marriage," while respecting the beliefs of others, the majority felt it was not realistic to add just the words "or civil union" to marriage for each of the innumerable state and national laws, as well as individual insurance contracts. It is accepted that the term marriage needs to be expanded to ensure that the health care and economic rights of those in committed same-sex unions (social security, taxes, inheritance, health insurance etc.) should not be inferior to those granted to the traditionally married. The Congress knows this is upsetting to many members and the vote was certainly mixed but believes it acted on the best evidence and most persuasive testimony. It is the AAFP’s hope that those opposing this decision can put it in balance with all of the good the AAFP does and all of the value AAFP membership brings so together we can remain strong. Another controversial resolution requested that CMS waive penalties for physicians over the age of 60 and in one–to two–person practices that do not adopt EMRs. There was much debate about the insufficient time to recover costs and possible forced early retirement versus the "slippery slope" argument of allowing exceptions especially when there has been nearly 10 years forewarning in which to prepare. In the end, a substitute resolution was passed asking the Board to "study both EMR adoption and PCMH transformation by family physicians that may face additional barriers to change, including, but not limited to, age, practice size and rural location, and determine the best ways to assist them in staying in practice." Clearly, the Congress expressed concern for those struggling with these expensive mandates but felt that we needed to continue forward "progress" and increase Academy resources to help FPs make the transitions. In a similar vein, there were two resolutions requesting the AAFP start a new "Section for Solo and Small Group Practices" within the AAFP. It was recognized that these practices are the "backbone of the Academy" yet economic and societal forces are threatening their existence and these practitioners need the support they would get by having their own Section. In the end, this too was referred to the

Congress of Delegates MAFP Board for study but don’t be surprised if their numbers entering primary care by a new section is established after better including those who choose Internal defining the section’s goals, membership, Medicine (IM) residencies – failing to and resulting fiscal note. mention that only 5% of IM residents On a related topic, the Congress stay in primary care. The Congress passed passed a resolution to direct the Academy a resolution requesting all U.S. medical to redouble efforts to study and combat schools annually report the number and forces leading to "Physician burnout," percentage of graduating students who now said to affect slightly over half of all select TRUE primary care residencies physicians. (which we then defined). Also, all U.S. The Congress long debated three medical schools will be requested to separate resolutions all proposing that report the number and percentage of Oral Contraceptive Pills (OCPs) should MAFP delegation and staff in attendance at COD included alumni practicing primary care five years (left to right, front row): Darryl Nelson, MD and Larry Rues, after graduation. Finally, the AAFP will be available OTC. While ACOG has MD; (back row) Keith Ratcliff, MD, Bruce Preston, MD, Bill conduct a survey of R-1 residents in Family already recommended in favor of this, Fish, MD, and Laurie Bernskoetter. Delegates expressed concerns about Medicine as to their medical school advice properly matching OCP chosen to regarding entering Family Medicine. patient type, as well as whether OCP was the best choice given the The Academy is to work with schools and uncover any "hidden higher protection of IUDs. In the end, the Congress ultimately curriculum" discouraging Family Medicine and we suggested ways to referred this to the Board for study. (As you know, Plan B "day help schools create a more supportive environment for producing after" contraception has already been approved by the FDA for sale primary care physicians. without a prescription). Jeffrey Cain, MD, is the board chair of the American Academy A number of resolutions proposed creating a category of duesof Family Physicians and Reid Blackwelder, MD, is president. paying, non-voting membership in the AAFP for Nurse Practitioners (NPs) and Physicians Assistants (PAs) who work directly with family Election Results physicians. Given the tensions and turf issues some physicians feel President- Elect – Robert Wergin, MD (Nebraska) about mid levels, this received much discussion. While many felt Speaker – John Meigs, Jr., MD (Alabama) PAs were less likely to seek independent practice, NPs may start in Vice Speaker – Javette Orgain, MD, MPH (Illinois) a collaborative practice arrangement but evolve to independents. Board of Directors: How would the AAFP monitor that and would it then revoke Wanda Filer, MD, MBA (Pennsylvania) membership? As usual the AAFP staff did an excellent job trying Rebecca Jaffe, MD, MPH (Delaware) to estimate the potential benefits to membership as well as the Daniel Spogen, MD (Nevada) monitoring costs and even potential loss of a few disgruntled active Carlos Gonzales, MD (Arizona) family physician members. In the end, the Congress gave the Board H. Clifton “Clif” Knight, MD (Indiana) more work by referring this for a report and a recommendation by Lloyd Van Winkle, MD (Texas) next year. Jack Chou, MD (California) Although not adopted by delegates, another resolution that Robert Lee, MD (Iowa) sparked considerable discussion asked the Academy to establish a Michael Munger, MD (Kansas) task force to consider changes to the current representation scheme Kisha Davis, MD, MPH, New Physician Member, (Maryland) in the Congress of Delegates to "one based on limited proportional Kimberly Becher, MD, Resident Member (West Virginia) representation as a means to increase member involvement and B. Tate Hinkle, Student Member (Alabama) representation in AAFP activities." Of course some saw this as the A recurring message from our AAFP leadership is that busy big vs. small states and worried how big the Congress would need to be if we change the senate-modeled system we now use. This is not family physicians must take time to get involved and to be leaders the first year this issue has been raised and arguments about fairness in the evolution of healthcare. Please do so. Again at this Congress, in representation vs. divisiveness will be considered by the task force and despite the challenging times and topics, Missouri delegates tried hard to promote the best interests of our patients, our the Board will appoint. The Congress considered a trio of workforce pipeline resolutions specialty, and the profession of Family Medicine. Thank you for the in the Reference Committee on Education, adopting two of them confidence and for this opportunity. and referring the third. There was testimony from your Missouri Academy that the amount of GME funding given to medical schools Respectfully submitted, Larry Rues, MD, Delegate should be proportional to the number of primary care physicians Darryl Nelson, MD, Delegate produced (especially family physicians). This possibility of using Keith Ratcliff, MD, Alternate Delegate GME funding to drive primary care numbers will be studied by Bruce Preston, MD, Alternate Delegate the Board. It is also known that medical schools often inflate Missouri Family Physician October - December 2013


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 oral antiviral therapy for localized herpes zoster safe and effective for preventing postherpetic neuralgia? Evidence-Based Answer

Oral acyclovir reduces the incidence of subacute postherpetic neuralgia (PHN) at 1 month, but does not reduce the incidence of PHN at 4 or 6 months after onset of rash (SOR: A, systematic review of RCTs). Famciclovir speeds relief of zoster pain, but does not decrease the incidence of PHN (SOR: B, single RCT). Valacyclovir may reduce PHN at 6 months compared with acyclovir (SOR: B, single comparative RCT). PHN is a painful complication of herpes zoster. Different definitions exist, ranging from pain immediately following rash healing to pain persisting more than 6 months after rash onset.1 A 2009 Cochrane review included 6 placebo-controlled RCTs evaluating the effectiveness of antiviral agents for preventing PHN (N=1,211).1 A subgroup meta-analysis of 4 trials including 692 patients showed a lower incidence of herpetic neuralgia 1 month after the onset of rash with acyclovir compared with placebo (44% vs 53%; RR 0.83; 95% CI, 0.71–0.96; P=.01; NNT=11). Additional meta-analyses within the Cochrane review showed the incidence of PHN was not significantly less with acyclovir than placebo at either 4 months (3 trials, N=609; RR 0.75; 95% CI, 0.51–1.1; P=.15) or 6 months after rash onset (2 trials, N=476; RR 1.1; 95% CI, 0.87–1.3; P=.62). The only study evaluating famciclovir included in the 2009 Cochrane review was a RCT of 419 immunocompetent adults who developed herpes zoster rash within the previous 72 hours.1 Famciclovir given at 500 or 750 mg 3 times daily for 7 days significantly reduced time to resolution of pain compared with placebo (63 days for 500 mg: HR 1.7; 95% CI, 1.1– 2.7; 61 days for 750 mg: HR 1.9; 95% CI, 1.2–2.9; 119 days for placebo). However, the incidence of PHN (defined as pain after rash healing and followed for 5 months) was similar in each of the 3 treatment groups: 44% (61 of 138 patients) for the 500-mg dose, 50% (68 of 135 patients) for the 750-mg dose, and 38% (56 of 146 patients) for placebo. A randomized trial of 1,141 patients aged 50 and older presenting within 72 hours of clinically diagnosed, localized herpes zoster compared acyclovir and valacyclovir.2 Patients were randomly assigned to 1 of 3 regimens: acyclovir 800 mg 5 times daily for 7 days, valacyclovir 1,000 mg 3 times daily for 7 days, or valacyclovir 6

Missouri Family Physician October - December 2013

July 2013 EBP

1,000 mg 3 times daily for 14 days. The proportion of patients with pain at 6 months was lower in those treated with valacyclovir (pooled data for both regimens) compared with acyclovir (19% vs 26%; P=.02; NNT=16). This trial was not included in the 2009 Cochrane review because it was not placebo controlled. Margaret Day, MD Kristen Deane, MD Luke Stephens, MD University of Missouri-Columbia Columbia, MO 1. Li Q, et al. Cochrane Database Syst Rev. 2009; (2):CD006866. [LOE 1a] 2. Beutner KR, et al. Antimicrob Agents Chemother. 1995; 39(7):1546–1553. [LOE 1b]

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.

THE STRENGTH TO HEAL and get back to what I love about family medicine. Do you remember why you became a family physician? When you practice in the Army or Army Reserve, you can focus on caring for our Soldiers and their Families. You’ll practice in an environment without concerns about your patients’ ability to pay or overhead expenses. Moreover, you’ll see your efforts making a difference. To learn more, visit us at

Missouri Family Physician October - December 2013


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MAFP Externship Experience

Family Health Foundation of Missouri offers clinical experience This summer I spent a month learning from and interacting with the faculty and residents at Research Family Medicine Residency in Kansas City, Missouri. I spent one week in labor and delivery, one Jenny Eichhorn, Student University of Missouri week on inpatient, Kansas City School of one week in clinic, Medicine and the last week I divided my time in the different areas. I also had the great opportunity to spend a couple of afternoons at an outreach OB clinic. Throughout my time in labor and delivery, I interacted with many residents and faculty. I saw several circumcisions, learning two different techniques, and numerous vaginal deliveries, some of which were quite complicated. I gowned-up and helped with a few of the deliveries and delivered the cord and placenta. I scrubbed in on a cesarean section with a resident and an attending, too. During my week on inpatient, I had a couple patients of my own that I followed throughout the week with a resident. I learned the importance of communication between team members for better patient care. In the afternoons, I helped admit new patients from the Emergency Department or went to various sub-specialty clinics which included the Integrative Medicine Clinic where I learned the basics of acupuncture and Colposcopy Clinic where I learned gynecological procedures, both from Family Medicine doctors. While in outpatient clinic, I worked with one or two residents each day. Depending on the resident and the workflow, I either worked with the resident on each patient or went in to see the patient by myself first. I gathered information from 8

Founded in 1988 by the Missouri Academy of Family Physicians as its philanthropic arm, the Family Health Foundation of Missouri, (FHFM) is dedicated to improving the health of Missouri families by supporting scientific, educational, and charitable activities through the field of Family Medicine. With AAFP Foundation matching funds, the FHFM sponsors four-week summer externships. FHFM is a 501 (c) (3) charitable corporation and contributions are tax deductible. To donate, visit:

the patient, did a focused physical exam, and presented the patient to the resident. Together, we came up with an assessment and plan for each patient. I helped with procedures in clinic including wound packing, pelvic exams, and toenail removals. I enjoyed this hands-on part of Family Medicine. I loved seeing patients of all ages in clinic; prenatal and well-child checks were very exciting and fulfilling. I also had the opportunity to travel to Harrisonville, Missouri to an OB outreach clinic that is staffed by faculty and residents from Research as well as volunteers from the community. This clinic helps all mothers in the area get prenatal care close to their home. I went to this clinic three times over the course of the month and plan to help

there in the future. I learned the basics of prenatal visits at this clinic, listened for fetal heart sounds, and practiced reading NST’s. I loved seeing some of the same patients each week for their visits as their due-date got closer. I got to know some of the patients and helped deliver one of their babies while at Research. Then, I helped do the newborn check on the baby later in my externship. This amazing relationship and trust between a doctor and their patient is truly special. I want to thank the MAFP for providing this great externship experience for me. I am evermore dedicated to becoming a great Family Physician and making wonderful, lasting relationships with my patients.


Missouri Health Professional Placement Services (MHPPS) is a non‐profit recruiting  service dedicated to rural and underserved areas of our great state!  We partner with  safety‐net providers and health care systems throughout Missouri to help health care  professionals, like yourself, find a community that best fits your personal and  professional needs.  Whether it’s a scenic rural setting, dynamic urban location, or  somewhere in between, we are committed to focusing on your interests and careers  that count!  Find Out More:  Joni Adamson   573.636.4222    jadamson@mo‐ 

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Missouri Family Physician October - December 2013

Externship Experience MAFP This year, I participated in the summer externship at Mercy Clinic Family Medicine in Creve Coeur, Missouri. After a year of learning basic science in medical school, I enjoyed the Michele Wong, Student Saint Louis University opportunity to School of Medicine apply my scientific knowledge to the clinical setting. Working in the clinic also reminded me of the reason I went into medicine, to care for a patient’s holistic health and well-being. The time I spent in the clinic with patients and learning from the family physicians reaffirmed my interest in primary care and family medicine. One of the first things that I observed was wide scope of family medicine. Upon realizing that I spent all my time in the outpatient clinic, my classmates would

ask if I would get bored, assuming I saw repeated upper respiratory tract infections cases. I actually saw a wide variety of patients, including seven-day-old infants, obstetrics patients, and elderly patients, who came for a wide variety of reasons, including health maintenance visits as well as acute health concerns. One of the PGY-3 residents I worked with would tell her patients, “Family medicine—it is your onestop-shop for anything you may need.” I saw that family physicians shaped their practice according to their interests within medicine, including dermatology, procedural medicine, obstetrics, and gynecology. My preceptor had experience in musculoskeletal disease and sports medicine. As he asked a detailed history about the injury and performed specific tests upon physical exam, I learned that a history alone often gives the necessary information to determine course of treatment. Didactic lectures presented a variety of topics including screening for alcohol abuse, medication guidelines,

common dermatological lesions and other topics. I was surprised to hear that family physicians have a role in helping couples with infertility, a concern that I would not have expected family physicians to address. In addition to the knowledge I gained observing physicians and learning in didactic lectures, this externship provided the opportunity for practical application of clinical skills. I practiced interviewing patients, listening to heart sounds, and performing physical exams. I also assisted the residents with obstetric visits, skin cancer excisions, steroid injections, and many other procedures. Throughout the four weeks I spent in the clinic, my preceptor and the residents took extra time to teach me and to involve me in the process of caring for each patient, and as a result I learned a great deal. My summer externship at Mercy Clinic Family Medicine Residency was both educational and enjoyable, and I believe that family medicine will be a rewarding career choice for me.

Family Medicine physicians are at the forefront of maintaining health in our medical system. This past june, I was given the opportunity to rotate at Truman Kevin Gray, Student Medical CenterUniversity of Missouri Lakewood, courtesy Kansas City School of Medicine of the AAFP Foundation and the Family Health Foundation of Missouri. As a future family medicine physician, my time at TMC-LW provided me with a full spectrum of clinical experiences ranging from the initial respirations of Labor and Delivery to health maintenance visits with elderly patients. While on the Labor and Delivery service, I was able to apply knowledge I had gained on the Obstetrics and Gynecology core rotation for more complete evaluation and management to the perinatal patients I encountered. I had the opportunity to

assist in vaginal and caesarean deliveries and subsequent discharge planning under the supervision of Dr. Vierthaler. While in the newborn nursery, I observed many circumcisions including the Mogen technique which I had not seen prior to my externship. Dermatology clinic with Dr. Silvers provided me with experience in cryotherapy, shave biopsies, and even excisional biopsies of infected cutaneous lesions of Neurofibromatosis type I, a rare condition that few have first hand experience with. In gynecology procedure clinic, Dr. Shaffer taught about indications and follow up for Colposcopies and LEEPs. Finally, I spent a week observing steroid and viscosupplement joint injections, fracture care, and concussion management in the sports medicine clinic with Drs. Gibson and Schultz. The externship allowed me to become more prepared for the upcoming months of interviews and match. I was able to talk to residents at all stages of training with regards to their experiences and suggestions for the selection of of a

residency program. Being a senior medical student, I was treated as a peer in training. Residents representing all scopes of family medicine, whether it be rural practice, those joining large private practices, or those pursuing fellowships, each had helpful advice to share. After my final day, I returned home prepared for my final year. The dedication of local providers has allowed for students to solidify their ambitions. It is with the unity of family medicine physicians and their associated medical team that the health of an entire state can be strengthened. As an officer of the UMKC Family Medicine Interest Group, I brought back my experiences of this unique opportunity to students aspiring to become the primary providers of the future. On behalf of all students selected to participate in the externship, I would like to thank the family medicine providers of Missouri for their sponsorship and commitment to the family medicine specialty.

Missouri Family Physician October - December 2013


MAFP Resident Grand Rounds

Evidence Supporting Success of Long-term Weight Loss Maintenance Jason Goergen, DO, PGY-2 Kavitha Arabindoo, MD, Faculty Research Family Medicine Residency Program Kansas City, Missouri Introduction While the prevalence of obesity in America is widely publicized, there is less discussion about obese individuals who are successful in achieving weight loss, and even less discussion about those who are able to sustain their weight loss long-term. Wing and Phelan defined long-term weight loss maintenance as “intentional loss of at least 10% of body weight and sustaining the weight loss for at least one year”.1 Data from the National Weight Control Registry (NWCR), a registry of self-selected population of more than 4,000 individuals over 18 years old who have lost at least 30 lbs. and kept it off at least 1 year, reported that approximately 20% of overweight or obese individuals are successful in accomplishing this goal.2 After individuals have successfully maintained their weight loss for 2-5 years, the chance of longer-term success greatly increases. The purpose of this article is to investigate the evidence behind the strategies that have been used to achieve long-term weight loss. Is there an effective diet for future weight maintenance? Numerous short-term studies have looked at the role of structured weight loss programs using various diets in long-term maintenance of weight loss. These diets mainly differ in their macronutrient composition and can be simply classified as: • High protein diet: high in protein, low in saturated fat; 34% of energy from protein, 20% of energy from fat, and 46% of energy from

carbohydrate3 • High carbohydrate diet: low in saturated fat, 17% of energy from protein, 20% of energy from fat, and 64% of energy from carbohydrate (e.g. Ornish Diet)3 • Low carbohydrate diet: <42% of energy from carbohydrates (e.g. Zone Diet)3 • Very low carbohydrate diet: 10% of energy from carbohydrate, 60% from fat, 30% from protein; low glycemic load (e.g. Atkins Diet)3 • Low fat diet: 60% of energy from carbohydrate, 20% from fat, 20% from protein; high glycemic load3 • Very low-energy diet: <800 Kcal/day4 • Hypoenergetic balanced diet: balanced macronutrients but keep energy intake below total daily energy expenditure4 A lower carbohydrate intake usually results in either a higher fat or a higher protein intake or both, and very-low-carbohydrate diets almost invariably result in higher saturated fat intake. Evidence behind the success of some of these diets in long-term weight loss maintenance is furnished below: • Clifton, et al compared High Protein (HP) diet to High Carbohydrate (HC) diet in a 64 week trial.3 Participants completed an intensive 12-week weight loss program after which they were randomized to either the HP or HC diet group for an additional 52 weeks. Although overall weight loss in the two allocated groups was not

10 Missouri Family Physician October - December 2013

Jason Goergen, DO

Kavitha Arabindoo, MD

significantly different, when actual protein intake was calculated from dietary records at 64 weeks, weight loss was greater in the reported highprotein group than in the reported low-protein group (6.5 +/- 7.5 kg vs 3.4 +/- 4.4 kg, P=0.03). • A meta-analysis of 29 US studies found that subjects that used Verylow-energy diets (VLED) to lose >= 20 kg initially were able to maintain weight loss more effectively than those that used Hypoenergetic balanced diets (HBD) and lost <10 kg initially (7.1 kg vs 2.0 kg) at the end of 5 years of follow up.4 • A low-fat dietary pattern that incorporated higher carbohydrate intake in the form of vegetables, fruits, and grains in post-menopausal women resulted in an initial 2.2 kg weight loss (P<0.001) and maintenance of this weight loss over 7 years of follow up.5 • A randomized trial of 773 participants across eight European countries looked at the influence of protein and glycemic index composition of diets on weight regain over a 26 week period.6 The study showed that a modest increase in protein content and a modest reduction in the glycemic index led to an improvement in study completion and maintenance of weight loss. A high dropout rate of 29% illustrates the difficulty in adhering to restrictive diets longterm. • A randomized trial of 322 moderately obese


Resident Grand Rounds MAFP

>> subjects looked at three different diets: low-fat, restricted-calorie; Mediterranean, restricted-calorie; or low-carbohydrate, non-restrictedcalorie.7 Subjects were followed to 2 years. The mean weight loss was 2.9 kg for the low-fat group, 4.4 kg for the Mediterranean-diet group, and 4.7 kg for the low-carbohydrate group (P<0.001). â&#x20AC;˘ A randomized trial of 811 overweight patients looked at the different weight-loss diets with different compositions of fat, protein, and carbohydrates over a 2 year period.8 Results showed that reduced-calorie diets resulted in clinically meaningful weight loss (4 kg) regardless of which macronutrients they emphasize. The trial also showed that the participants, after an initial weight loss of 6 kg in 6 months, started to regain weight after 12 months. While there are numerous diets available for patients to follow to achieve and maintain weight loss, the vast majority of these have not been studied in direct comparison. According to current AHA dietary guidelines, diets for weight reduction should be limited in total calories, with â&#x2030;¤30% of total calories as fat to predict a weight loss of 1 to 2 pounds per week (minus 500 to 1000 kcal/d).9 This diet should include vegetables, fruits, legumes, and whole-grain products and should be restricted in saturated fat and cholesterol. How much physical activity is required for weight (loss) maintenance? Although it is accepted that physical activity plays an important role in weight loss and weight maintenance,1 there has been discussion regarding the amount of physical activity required to maintain weight loss. The Center of Disease Control and Prevention recommends energy expenditure of 1000 kcal per week, equivalent to walking 30 minutes per day, 7 days a week for general health maintenance.10 More recently, the 2005 Dietary Guidelines for Americans recommends 60 minutes of moderate

physical activity per day which corresponds to 2100 kcal per week.9 Tate et al performed a randomized prospective study to determine if higher energy expenditure resulted in improved long-term weight loss maintenance.10 Two hundred and two overweight adults were randomized to either 18 months of standard behavioral treatment (SBT) with an exercise goal of 1000kcal/wk or a high physical activity (HPA) treatment with a goal of 2500 kcal/wk. The HPA group achieved significantly greater exercise levels and weight losses than did the SBT group at 12 and 18 months (P <0.01). When followed to 30 months however, weight loss did not differ significantly between the two groups due to a decline in activity levels in the HPA group. Participants who reported continuing to engage in high levels of exercise maintained a significantly larger weight loss. How effective are behavioral weight loss interventions for long-term weight loss maintenance? Behavioral weight loss interventions have been shown to achieve short-term success, but regain is common. Weight regain is believed to result from physiological adaptations, principally an increase in hunger and a decrease in resting energy expenditure.11 There have been several trials that have looked at various behavioral strategies in stopping this weight regain such as the Trials of Hypertension Prevention Phase II (TOHP-II), STOP Regain trial and The Weight Loss Maintenance (WLM) Randomized controlled trial.12 The WLM trial was a 2-phase trial that enrolled 1032 overweight or obese adults with hypertension, dyslipidemia, or both. Phase 1 intervention was a group-based behavioral intervention with weekly group sessions over 6 months that focused on 180 minutes per week of moderate physical activity, reduced caloric intake, the DASH diet and weight loss goals of 1-2 lbs per week. Participants who had lost at least 4 kg at the end of phase 1 were then randomized to one of 3 groups as part

of phase 2 â&#x20AC;&#x201C; a self-directed control group in which participants received minimal intervention, an interactive technologybased intervention in which participants were encouraged to regularly log on to an interactive Website, and a personal-contact intervention in which participants had monthly individual contact. All 3 groups were followed up to 30 months. Primary outcome measures were change in weight from randomization (the start of phase 2) to the end of the study as well as change in weight from entry into study. During the initial 6-month program, mean weight loss was 8.5 kg. After randomization, weight regain occurred. Participants in the personal-contact group regained less weight (4.0 kg) than those in the interactive technology-based group (5.2 kg) and the self-directed group (5.5 kg). Despite some weight regain, the majority of individuals who successfully completed an initial 6-month behavioral weight loss program maintained weight below their entry level after 30 additional months with the greatest benefit noted in individuals that had at least monthly personal contact. Similar results were noted in a Randomized Controlled Trial investigating the effect of a free prepared meal (nutritionally adequate, low-fat, reducedenergy diet) and incentivized weight loss program on weight loss and weight loss maintenance in obese and overweight women.13 In-person center-based or telephone-based individual weight loss counseling resulted in greater weight loss and weight loss maintenance than the usual care group (7.4 kg vs 2.0 kg, P<0.001) at the end of 24 months. Conclusion Even modest amounts of weight loss of approximately 10% in 1 year have been shown to significantly reduce the risk of diabetes and cardiovascular disease risk factors.14 The triple factor combination of 1) low calorie diet to match daily expenditure, 2) moderate amounts of physical activity to achieve initial and sustain long-term weight loss and 3) behavioral continued on page 13 interventions will

Missouri Family Physician October - December 2013


MAFP Fall Conference/Family Physician of the Year

Earn up to 13.50

CME credits

Register online it's or register onsite


Join us for the Visit • Registration Form • Room Reservation Form • Schedule of Events & Speakers

21st Annual Fall Conference and SAM Study Group to be held at Big Cedar Lodge, Ridgedale, Missouri November 8-9, 2013

Nominate the 2014 MAFP Family Physician of the Year Do you have an outstanding, caring colleague or physician in your community that deserves the title “Missouri Family Physician of the Year?" The Missouri Academy of Family Physicians (MAFP) supports over 1,100 active members in the work-force ~ doing extraordinary things every day. You know them, and we would like to acknowledge them. MAFP is now seeking nominations for this prestigious award. Nominate your family physician or a family physician that you know! Nominations may be made by any member of the MAFP or the public.

Visit our website at to find everything you need: • Nomination Form • Nomination & Selection Process • Past Winners • Judging Criteria • Eligibility Requirements & Limitations You may also request information by calling MAFP at (573) 6350830 or by emailing . The winner will be honored at the MAFP Annual Meeting in June 2014. (Mail, fax, e-mail or online submissions are accepted)

Nominations due by March 1, 2014 12 Missouri Family Physician October - December 2013

Resident Grand Rounds MAFP

Long-term Weight Loss Maintenance continued from page 11 assist individuals in maintaining weight loss. References 1. Wing R, Phelan S. Long-term weight loss maintenance. 2005; 82:222S-225S. 2. Klem M, Wing R, McGuire M, Seagle H, Hill J. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr. 1997; 66:239-246. 3. Clifton P, Keogh J. Long-term effects of a high-protein weight-loss diet. Am J Clin Nutr. 2008; 87:23-9. 4. Anderson J, Konz E, Frederich R, Wood C. Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr. 2001; 74:579-584. 5. Howard B, Manson J, Stefanick M. Low-fat dietary pattern and weight change over

7 years: The Women’s Health Initiative Dietary Modification Trial. JAMA. 2006; 295:39-49. 6. Larsen T, Kalskov S, Van Baak M. Diets with high or low protein content and glycemic index for weight-loss maintenance. NEJM. 2010; 363:22 7. Shai I, Schwarzfuchs D, Henkin Y etal. Weight Loss with a low-carbohydrate, Mediterranean, or low-fat diet. NEJM. 2008; 359(3): 229-241. 8. Sacks F, Bray G, Carey V. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. NEJM 2009; 360:9. 9. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government Printing Office; 2005. 10. Tate D, Jeffery R, Sherwood N, Wing R. Long term weight losses associated with prescription of higher physical activity goals: Are higher levels of physical activity





protective against weight regain? Am J Clin Nutr. 2007; 85:954-959. Leibel R, Rosenbaum M, Hirsch J. Changes in energy expenditure resulting from altered body weight. NEJM. 1995; 332:621-628. Svetkey L, Stevens V, Brantley P. Comparison of strategies for sustaining weight loss. JAMA 2008; 299(10):11391148. Rock C, Flatt S, Sherwood N. Effect of a free prepared meal and incentivized weight loss program on weight loss and weight loss maintenance in obese and overweight women. JAMA. 2010;304(16): 1803-1811. Pi-Sunyer X, Blackburn G, Brancati F, et al. Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care. 2007; 30(6):1374-1383.

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888.50.Allergy | Missouri Family Physician October - December 2013


MAFP Members in the News

Members in the news Kansas City University of Medicine and Biosciences (KCUMB) appointed Jeffrey A. Suzewits, DO, MPH, FAAFP, FAODME, as associate dean of clinical education in July. Dr. Suzewits comes to KCUMB from A.T. Still Universityâ&#x20AC;&#x2122;s Kirksville College of Osteopathic Medicine (KCOM) in Kirksville, Mo., where he served as acting associate dean for academic affairs, associate dean for clinical educational affairs and associate professor of family medicine, preventive medicine and community health. George Harris, MD, has accepted a new position as Chair of the Department of Family Medicine at West Virginia Univeristy School of Medicine-Eastern Division and as Medical Director of the Primary Care Division of University Healthcare Physicians, Inc. After ten years of service, he leaves his post as Professor and Assistant Dean Year 1 and 2 Medicine at UMKC School of Medicine and the Associate Director of the Sports Medicine fellowship. Dr. Harris has served on numerous committees and councils for AAFP, Missouri Academy of Family Physicians, Florida Academy of Famliy Physicians and AMA. He has been a member of AAFP since 1985, past president of the Florida Academy, and most recently served as a Missouri Academy Board Member, co-chair of the Member Services Commission, and medical co-editor of the Missouri Family Physician magazine.

On August 2, 2013, the students and residents elected two Alternates to the MAFP Board at the Missouri Reception in Kansas City which is held in conjunction with NCFMRS. Betsy Wan, MD (SLU FMR) was elected as the Alternate Resident Director and Sarah Williams (MU) was elected as the Alternate Student Director. They will serve their first year as Alternate and the second year as Director for a total of two years.

Pictured above, left to right are Sarah Williams (MU), newly elected Alternate Student Director, and Amanda Williams (UMKC), Student Director. Pictured left are Imani Anwisye, MD (SLU FMR) (left), Resident Director, and Betsy Wan, MD (SLU FMR) (right), newly elected Alternate Resident Director.

The Saint Louis University School of Medicine Family Medicine Interest Group (FMIG) was one of ten recipeints of the 2013 Program of Excellence (PoEP Awards as an overall winner. FMIG Representatives accepted the award and were recognized at the FMIG breakfast held on August 2, 2013, at the AAFP NCFMRS in Kansas City. Pictured above, left to right: Swetha Gogineni, Risa Garcia, Monica Kao, Michele Wong, and Charonn Woods. All are currently MS2s at Saint Louis University School of Medicine.

14 Missouri Family Physician October - December 2013

Missouri Tar Wars MAFP

Missouri Tar Wars Program Receives Recognition What is Tar Wars? Tar Wars, celebrating celebrating its 25th anniversary this year, is a school-based tobaccofree education program for fourth-and fifth-grade students in your community. The program is designed to teach children about the short-term health effects and image-based consequences of tobacco use, and about being tobacco free by providing them tools to make positive decisions regarding their health and promote personal responsibility for their well being.

Monique Arroyo, pictured above, the Missouri first place poster winner traveled to Washington, DC July 15-16, 2013, to participate in the annual Tar Wars National Conference. At the conference, poster winners and their families visited with legislators to advocate for tobacco-free issues and family medicine. 2013 Missouri Tar Wars poster winners: 1st Place - Monique Arroyo South Holt R-1 School, Oregon, Missouri 2nd Place - Rhett Hall Mound City R-2 School, Mound City, Missouri 3rd Place - Rachel Szala St. Therese School, Kansas City, Missouri 4th Place - Claire Russell Blair Oaks Elementary School, Jefferson City, Missouri 5th Place - Logan Tracy Santa Fe Elementary School, Waverly, Missouri Also recognized at the National Conference were Nancy Griffin, MAFP Staff and Tar Wars Coordinator, and Susan Lentz, RN, BSN, long-time Tar Wars presenter and supporter. Griffin received the Recognition of Service Award for leadership, contributions, and commitment to the Tar Wars effort while serving as a Tar Wars Program Advisor. She also served on the 2012-2013 National Tar Wars Advisory Council. Lentz received the Tar Wars Star Award for Service. She is the school nurse for three Missouri elementary schools, Craig R-3, Mound City R-2, and South Holt R-1 and has been utilizing the Tar Wars curriculum for all fifth-grade students annually since 1998. The Tar Wars Star Award honors individuals and organizations who have significantly contributed to the Tar Wars effort. Star Awards are presented annually at the Tar Wars National Conference.

Program Goals • Increase knowledge of short-term health effects and imagebased consequences of tobacco use • Illustrate cost/financial impact cost of using tobacco and ways money could be better spent • Identify reasons why people use tobacco • Explain how tobacco advertising, tobacco use in movies, and the tobacco industry markets their products to children Who can present Tar Wars? You can! You can make a difference in the health of your community by educating as many children as possible about the harmful effects of tobacco use. Family physicians, family medicine residents and medical students, school nurses and nurse practitioners, physician assistants, other health care providers, dental hygienists, health education professionals, community leaders, and even parents can present Tar Wars. You don't need special training or a specific background to get involved. Your volunteer efforts and enthusiasm are key elements in the success of the program. More about Tar Wars Tar Wars has shown to be effective in increasing students’ knowledge of and attitudes toward tobacco use and advertising and should be considered as one of the building blocks in your school’s comprehensive, tobacco prevention education plan. The Tar Wars program has been implemented in all 50 states, several territories and internationally, and has reached more than 9 million children. Tar Wars is consistent with the guidelines for youth tobacco prevention programs set forth by the Centers for Disease Control and Prevention. Questions? For an updated presenters guide or for more information, please visit If you have questions about the poster contest, please contact Nancy Griffin at (573) 635-0830 or email: Missouri Family Physician October - December 2013


MAFP Resident Grand Rounds

PreDiabetes Screening and Treatment in 2013 Jay Patel, DO, PGY-2 Jennifer Kelley, MD, Faculty Jon Welsh, MD, Faculty Research Family Medicine Residency Program Kansas City, Missouri

Introduction The natural progression of diabetes has a prolonged prediabetic phase allowing early recognition and targeted intervention in high risk patients. Prediabetes is a state of abnormal metabolism defined by glucose levels elevated between normal and those not high enough to be classified as diabetes and is associated with metabolic syndrome and an increased cardiovascular risk.1 Aggressive lifestyle intervention and selective pharmacologic therapy (e.g. metformin) have been shown to delay and prevent the onset of diabetes. Diagnosing Prediabetes The 2013 American Diabetes Association (ADA) defines prediabetes as an impaired fasting glucose (IFG) between 100 and 124 mg/dL, an impaired glucose tolerance (IGT) between 140 and 199 mg/dL, or a hemoglobin A1c between 5.7 and 6.4 percent.2 By 2010, approximately 35 percent of Americans above the age of 20 (76 million adults) had prediabetes, an increase of 9 percent from 2002.3 Among adolescents, obesity has risen from 5 percent in 1980 to 18 percent in 2010 and is reflected by the prevalence of IFG in 1 of 10 boys and 1 in 6 overweight adolescents by 2000.4,5 Risk Factors Groups at increased risk for developing diabetes include those with a BMI > 25 kg/m2, a history of gestational diabetes, high blood pressure, inactive lifestyle, HDL < 35 and triglycerides > 250.6 People with African American, Native American, Alaska Native, Hispanic, and Pacific Islander ethnic backgrounds are

Jay Patel, DO

at increased risk. South Asians and Chinese tend to have a lower BMI at time of diagnosis of diabetes compared to Caucasians.7 Certain medications can cause increased risk for developing prediabetes, specifically antipsychotics secondary to weight gain, statins, and antiretroviral therapy for HIV (HAART and NRTIs).2 Screening for Prediabetes The 2013 ADA guidelines recommend screening adults of any age who are overweight or obese (BMI >25) and have 1 or more additional risk factors. “Additional risk factors” include those listed above plus those with a first-degree relative who is diabetic, women who have had a baby that weighed more than 9 pounds, women with polycystic ovary syndrome, acanthosis nigrans, or previous abnormal A1C or glucose tolerance test.6 Screening in children also includes those in the overweight category plus 2 additional risk factors.6 Additional risk factors for children include family history of diabetes in first or second degree relatives, race/ ethnicity, signs/conditions associated with insulin resistance (hypertension, acanthosis nigrans, small-for-gestational-age birth weight), maternal history of GDM. Note that the age to initiate screening in children is 10 years old or at onset of puberty. The ADA adopted hemoglobin A1c as a form of screening for prediabetes in 2010. The gold standard still remains the oral glucose tolerance test (OGTT) which is a measurement of serum glucose after a 75 gm load of glucose.6 However, either an HbA1c, a fasting glucose or an OGTT

16 Missouri Family Physician October - December 2013

Jennifer Kelley, MD

Jon Welsh, MD

may be used to screen for prediabetes. In certain conditions, acute blood loss, sickle cell disease, pregnancy, or recent blood donation/transfusion, HbA1c cannot be used as a screening test. Regardless of the test being used, a repeat test on a separate occasion is required for diagnosis. The American Academy of Clinical Endocrinologists (AACE) recommends that a glucose test (either a fasting glucose or OGTT) be used for confirmation of an elevated HbA1c in the diagnosis of prediabetes.2 Epidemiological studies forming the framework for recommending use of the HbA1C to diagnose diabetes have all been in adult populations.6 Negative screening for prediabetes should be followed by rescreening every 3 years or as indicated by comorbid conditions and clinical symptoms per ADA guidelines.6 Individuals with diagnosed prediabetes should be screened yearly to monitor progression of disease and manage comorbid conditions. Patients with a confirmed elevated HbA1c can be further risk stratified.6 Those with an HbA1c between 5.5 and 6.0 percent have a 9–25% chance of developing diabetes in the next 5 years. Those with an HbA1c between 6.0 and 6.4 percent have a 25–50% chance of developing diabetes in 5 years. As the HbA1c rises, the risk for diabetes rises disproportionately and those with an HBA1c > 6 percent should be considered very high risk. The HbA1c has also been shown to be more strongly correlated with future development of diabetes and cardiovascular disease in undiagnosed population when


Resident Grand Rounds MAFP

>> compared to a fasting blood glucose.


Women with a history of gestational diabetes (GDM) have up to a 70 percent lifetime risk of developing diabetes, therefore, post partum screening is important.9 At the first 6-week post partum visit and then at least every 3 years afterwards, women with a history of GDM should be screened.6 Treatment of Prediabetes The Diabetes Prevention Program (DPP), a large multicenter prospective study of 3,234 prediabetics compared intensive lifestyle modification (ILM) and metformin therapy with a placebo.10 Patients were followed for a minimum of 3 years. ILM goals were defined as a 7 percent weight loss and moderate activity, such as a brisk walk, for at least 150 minutes a week. Patients treated with metformin were given an 850 mg dose twice daily. There was a 58% reduction in the development of diabetes in ILM group and a 31 percent reduction in the metformin group when compared

to placebo. Patients (n=2,766) followed for an additional 5.7 years demonstrated a 34% reduction in development of diabetes in the ILM group and a 18% reduction in the metformin group when compared with placebo. Similar long term prospective studies of prediabetic patients have shown similar results.11,12 Analysis of the DPP and the Diabetes Prevention Program Outcomes Study has shown that both intensive lifestyle modification and metformin are cost effective in the treatment of prediabetes.13

and/or prevention of diabetes in patients with prediabetes:6 • All prediabetics should be screened for modifiable risk factors for cardiovascular disease and treated accordingly. • All patients with prediabetes should be referred to an effective support program with a goal of 7% weight loss and 150 minutes of moderate activity weekly with a focus on follow up counseling. • Metformin is strongly recommended in patients with prediabetes, a BMI > 35 kg/m2 and age less than 65, or women with a history of gestational diabetes. • Annual monitoring of patients with prediabetes should be done to evaluate for progression to diabetes.

In addition to setting goals for patients, treatment includes the important aspect of continued education. Having a structured education program can enhance adherence with diet and exercise recommendations and motivate patient to continue to improve. Resources are available online to implement a 16 week curriculum.14

References Conclusion The 2013 ADA guidelines recommend the following clinical practices for the delay


The Diabetes Prevention Program Research Group. Reduction in the incidence of continued on page 19

Missouri Family Physician October - December 2013


Graham Center Policy One-Pager MAFP Historic Growth Rates

Historic Growth Rates Vary Widely Across the Primary

Historic Growth Rates Vary Widely Across the Primary Care Physician Disciplines Care Disciplines LAUrA A.Physician MAkAroFF, Do; LArry A. GreeN, MD; STePheN M. PeTTerSoN, PhD; JAMeS C. PUFFer, MD; roberT L. PhILLIPS, MD, MSPh; and ANDreW W. bAzeMore, MD, MPh

Laura A. Makaroff , DO; Larry A. Green, MD; Stephen M. Petterson, PhD; James C. Puffer, MD;aRobert L. Phillips , MD, MSPH; and W. rate. Ba zemore, MD, MPH Nested within 40-year trend of specialty-to-population moreAndrew and at a steeper The aging population, declining growth outpacing that of primary care is variability in medical student interest in primary care,2 and increased the rate of expansion within the different primary care interest in hospitalist careers3 portend a likely crisis for Nested within1 a 40-year trend of specialty-to-population growth declining medical student interest in primary care,2 and increased disciplines. continued trends, adult primary care careers workforce to provide accessible, 3 outpacing that With of primary care ispopulation variability inaging the rate of low the interest in hospitalist portend a likely crisis for the adult annual birth expected health insurance 1expancomprehensive to those in need.accessible, The increase in gen- care expansion withinrate, the and different primary care disciplines. With primary carecare workforce to provide comprehensive sion, it ispopulation vital that physician workforce policy be rate, aimed at eral to pediatricians hasThe greatly outpaced a declining annual continued aging trends, low annual birth and those in need. increase in general pediatricians has greatly meeting population needs to deliver optimal primary care. birth rate with a continued need for pediatric subspecialexpected health insurance expansion, it is vital that physician outpaced a declining annual birth rate with a continued need for 4 Insurance expansion4 under the expansion Affordableunder Carethe ActAffordable Familypolicy medicine, general internal medicine,needs and general workforce be aimed at meeting population to deliver ists.pediatric subspecialists. Insurance will cover several million more children, but also will pediatrics comprise the majority of the primary care phyoptimal primary care. Care Act will cover several million more children, but also will cover millions more adults—many sician workforce ingeneral the United States. To better Family medicine, internal medicine, andunderstand general cover millions more adults—manywith withpent-up pent-up demands demands for care, pediatrics the majority of the primary care physician and most located in underserved areas. Primary and most located in underserved areas. care workforce trends incomprise the primary care physician workforce, we have for care, workforce in the the growth United States. To better understand trends in the Primary need projections are more complex than ever, with care workforce need projections are smaller more patient examined of family physicians, general pediaprimary careand physician have examined thepatient growth complex panelthan sizes ever, reflective medicalpatient home tenets, increasing withofsmaller panel sizes reflec-part-time tricians, generalworkforce, internistsweproviding direct ofcare family generalfigure). pediatricians, and general internists tive work, and career shifts away increasing from full-time direct patient of medical home tenets, part-time work,care.5 (seephysicians, accompanying providing direct patient care (see accompanying figure). toward furtherdirect characterization of 5the careerefforts shiftsdirected away from full-time patient care. The physician-to-population ratio among all primary andPolicy Thephysicians physician-to-population among allfor primary carethe Policy unique, individual contributions of the characterization primary care specialties to efforts directed toward further care has increasedratio consistently at least physicians has increased consistently for at least the past three the delivery of optimal primary care, coupled with the alignment primary past three decades. The family medicine and general of the unique, individual contributions of the decades. The family medicine and general internal medicine of appropriate workforce production, could help improve internal medicine physician-to-target population ratios care specialties to the delivery of optimal primary care, access to physician-to-target population ratios have shown small incremental primary care for millions of patients in the United States. have shown small incremental growth, whereas the gen- coupled with the alignment of appropriate workforce growth, whereas the general pediatrician-to-target population ratio eral pediatrician-to-target population ratio has increased production, could help improve access to primary care for has increased more and at a steeper rate. The aging population, The information and opinions contained in research from the Graham Center do millions of patients in the United States. not necessarily reflect the views or the policy of the AAFP. The information and opinions contained in research from the Graham Center do not necessarilyare reflect the views or the policyCenter of the at AAFP. Policy One-Pagers available from the Graham http://www.graham-

Physicians per 100,000 target population

60 50 One-Pagers are available from the Graham Center at http://www.


Author disclosure: No relevant financial affiliations.


Author disclosure: No relevant financial affiliations.

20 10



0 1980




Year General internal medicine General pediatrics

General practice/ family medicine

Figure. Primary care physician workforce growth per tarFigure. Primary care physician workforce growth per target get population. population.

Each primary care specialty is denominated by its target population: General practice/family medicine denominated by entire population, general NOTE: primary care specialty is denominated byolder), its target internalEach medicine denominated by adult population (19 years and and pediatrics denominated by child populationmedicine (younger than 19 years). by population: General practice/family denominated NOTE:

1. Makaroff LA, etLA, al.etTrends in physician supply growth. 1. Makaroff al. Trends in physician supplyand andpopulation population growth. Am Fam Am Fam Physician. 2013;87(7). Physician. 2013;87(7). Accessed June od3.html. Accessed June 10, 2013.

10, 2013.

2. Hauer KE, et al. Factors associated with medical students’ career 2. Hauer KE, etinternal al. Factors associated with medical students’ career choices regarding choices regarding medicine. JAMA. 2008;300(10):1154-1164.

medicine.inJAMA. 2008;300(10):1154-1164. 3. Kuo YF,internal et al. Growth the care of older patients by hospitalists in the United States. N al. Engl J Med. 2009;360(11):1102-1112. 3. Kuo YF, et Growth in the care of older patients by hospitalists in the United 4. Freed GL, et Nal.Engl Oversimplifying primary care supply and shortages. States. J Med. 2009;360(11):1102-1112. JAMA. 2009;301(18):1920-1922.


Freed GL, et al. Oversimplifying primary care supply and shortages. JAMA.

5. U.S. Department of Health and Human Services. Health Resources and 2009;301(18):1920-1922. Services Administration. Bureau of Health Professions. December 2008. 5. physician U.S. Department of Health and Human Resources and Services The workforce: projections and Services. researchHealth into current issues Administration. of Health Professions. December 2008. The physician affecting supply andBureau demand. ■ affecting supply and reports/physwfissues.pdf. June 10, 2013.issues workforce: projectionsAccessed and research into current

Data population, from Americangeneral Medicalinternal Association Physiciandenominated Masterfile (2000 entire medicine by to adult 2010), Area Resource File (1980 to 2000), and U.S. Census (1980 to 2010). population (19 years and older), and pediatrics denominated by demand. Accessed child population (younger than 19 years). June 10, 2013.■ October 1, 2013 ◆ Volume 88, Number 7 American Family Physician 1 Data from American Medical Association Physician Masterfile October 1, 2013 • Volume 88, Number 7 • • American Family Physician (2000 to 2010), Area Resource File (1980 to 2000), and U.S. Census (1980 to 2010).

18 Missouri Family Physician October - December 2013

Resident Grand Rounds MAFP

PreDiabetes continued from page 17 type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393– 403. 6. 2. AACE Task Force for Developing Diabetes Comprehensive Care Plan. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice 7. for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011 Mar-Apr;17 Suppl 2:1-53. 3. Centers for Disease Control and Prevention. 8. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. 9. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2011. 4. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in 10. body mass index among US children and adolescents, 1999-2010. JAMA. 2012; Feb 1;307(5):483-90. 5. Williams DE, Cadwell BL, Cheng YJ, et al. Breakfast Works_hlf pg_4C:half 5/8/13 Prevalence of impaired fastingpage glucose and 9:19 AM

its relationship with cardiovascular disease risk factors in US adolescents, 1999-2000. Pediatrics. 2005; Nov;116(5):1122-6. American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care. 2013; 36 Suppl 1:S11. Chiu M, Austin PC, Manuel DG, Shah BR, Tu JV. Deriving ethnic-specific BMI cutoff points for assessing diabetes risk. Diabetes Care. 2011; Aug;34(8):1741-8. Selvin E, Steffes MW, Zhu H, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med. 2010; Mar 4;362(9):800-11. Ratner RE, Christophi CA, Metzger BE, et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab. 2008; Dec;93(12):4774-9. Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Page Lancet.1 2009 November 14; 374(9702):

1677–1686. 11. Tuomilehto J, Lindström J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001; May 3;344(18):1343-50. 12. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care. 1997; Apr;20(4):537-44. 13. The Diabetes Prevention Program Research Group. The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med. 2005; 142:323–332. 14. The George Washington University Biostatistics Center. DPP Coordinating Center. index.htmlvdoc. Published August, 2001. Accessed, February 21, 2013.

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Missouri Family Physician October - December 2013


MAFP Help Desk Answers

How often should serum protein electrophoresis be done in someone with monoclonal gammopathy of undetermined September 2013 EBP significance (MGUS)? Evidence-Based Answer

Patients with an initial diagnosis of MGUS should have a serum protein electrophoresis (SPEP) rechecked in 6 months. Risk stratification by free-light chain (FLC) ratio, immunoglobulin (Ig) type, and serum monoclonal (M) protein level is warranted. Low-risk patients should have SPEP every 2 to 3 years, while patients with higher-risk MGUS should have SPEP every year (SOR: C, expert opinion). A cohort of 1,148 patients with MGUS, defined as a serum M protein <30 g/L, bone marrow plasma cells <10%, and the absence of end-organ damage attributable to the plasma cell proliferative disorder, were followed for a median of 15 years.1 Risk of progression to malignancy correlated with 3 characteristics: kappato-lambda FLC ratio <0.26 or >1.65 (HR 2.6; 95% CI, 1.7–4.2), serum M protein level >15 g/dL (HR 2.4; 95% CI, 1.7–3.5), or non-IgG type MGUS (HR 2.6; 95% CI, 1.7–4.0). The 20-year risk of malignant progression in patients with 3 risk factors was 58%; in patients with 2 risk factors, the 20-year risk was 37%; in patients with 1 risk factor, the 20-year risk was 21%; and in patients with no risk factors it was 5%. A limitation of the study was the lack of detailed characterization of the 32% of patients who were not followed until death. In a non–risk-stratified cohort of 241 patients with MGUS followed for a median of 13 years, the interval between diagnosis of MGUS and the diagnosis of multiple myeloma or a related disorder ranged from 1 to 32 years, with a rate of progression of 1.5% per year.2 Based on these 2 cohort studies, the International Myeloma Working Group recommended that patients with low-risk MGUS have a SPEP repeated at 6 months and then every 2 to 3 years and that patients with a kappa-to-lambda FLC ratio <0.26 or >1.65, serum M protein level >15 g/dL, or non-IgG type MGUS have SPEP repeated in 6 months and then annually for life.3


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Christine K. Jacobs, MD St. Louis University FMR St. Louis, MO 1. Rajkumar SV, et al. Blood. 2005; 106(3):812–817. [LOE 2b] 2. Kyle RA, et al. Mayo Clin Proc. 2004; 79(7):859–866. [LOE 2b] 3. Kyle RA, et al. Leukemia. 2010; 24(6):1121–1127. [LOE 2a] 20 Missouri Family Physician October - December 2013

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

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