Fall 2017 (October-December)

MISSOURI Official Publication of the Missouri Academy of Family Physicians

Family Physician

October-December 2017 Volume 36, Issue 4

Congress of Delegates Recap New Officers, Resolutions and Reports Page 34 Annual Fall Conference Register Today Page 31 Advocacy Day Be the Voice of Missouri Family Physicians Page 33 Resident Composites Page 36

ISSUE FOCUS:

RECOGNIZING & COPING WITH PHYSICIAN BURNOUT

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executive commission Board Chair - Kathleen Eubanks-Meng, DO (Blue Springs) President - Mark Schabbing, MD (Perryville) President-Elect - Sarah Cole, DO, FAAFP (St. Louis) Vice President - Jamie Ulbrich, MD, FAAFP (Marshall) Secretary/Treasurer - James Stevermer, MD, FAAFP (Fulton)

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Director: John Burroughs, MD (Kansas City) Alternate: Jared Dirks, MD (Kansas City) Director: Lisa Mayes, DO (Macon) Alternate: Vacant Director: Emily Doucette, MD (St. Louis) Director: Kara Mayes, MD (St. Louis) Alternate: Dawn Davis, MD (St. Louis) Director: Jennifer Scheer, MD, FAAFP (Gerald) Alternate: Kristin Weidle, MD (Washington) Director: Vacant Alternate: Vacant Director: David Pulliam, DO, FAAFP (Higginsville) Alternate: Carrie Peecher, DO (Marshall) Director: Wael Mourad, MD, FAAFP (Kansas City) Director: Afsheen Patel, MD (Kansas City) Alternate: Kelsey Ryan, MD (Kansas City) Director: Mark Woods, MD (Ozark) Alternate: Charlie Rasmussen, DO, FAAFP (Branson) Director: Patricia Benoist, MD, FAAFP (Houston) Alternate: Vacant Director: Deanne Siemer, MD (Jackson) Alternate: Vicki Roberts, MD, FAAFP (Cape Girardeau)

resident directors Alicia Brooks, MD, SLU Ann Lottes, MD, SLU (Alternate) student directors John Heafner, MSPH, SLU MiMi Liu, SLU (Alternate) aafp delegates

MAFP 25th Annual Fall Conference & KSA November 10-11, 2017 Big Cedar Lodge, Ridgedale, MO

MAFP Advocacy Day February 19-20, 2018 Capitol Plaza Hotel, Jefferson City, MO

AAFP Annual Chapter Leadership Forum/National Conference of Constituency Leaders April 26-28, 2018 Sheraton at Crown Center, Kansas City, MO MAFP Annual Scientific Assembly June 8-9, 2018 The Lodge at Old Kinderhook, Camdenton, MO

INSIDE THIS ISSUE Pg. 4 6 8 22 25 26 28 30 33 34 36 42

Board Chair Report President's Report FOCUS: Addressing Burnout National Conference Recap Statewide WIC Program FPIN: Help Desk Answers Members in the News AFC Schedule of Events & Registration Form Advocacy Day Congress of Delegates Recap Resident Composites IA, MO, NE CME Cruise

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Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Alternate Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate mafp staff Executive Director - Kathy Pabst, MBA, CAE Communications and Education Manager - Sarah Mengwasser Membership and Programs Coordinator - Becki Hughes Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 f. 573.635.0148 www.mo-afp.org office@mo-afp.org The information contained in Missouri Family Physician is for information purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinion expressed in each article(s) is the opinion of its author(s) and does not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no responsibility for the opinion expressed thereon.

MO-AFP.ORG 3

I Want to be an Elementary School Janitor

T

his article’s deadline was four days ago. Ironically, physician burnout is the topic. Topic research was performed, a timeline in place for copy well ahead of schedule, and solid content outline in place. Then, the life of a family medicine physician, wife and mother of three teenage girls intervenes. When I entered medicine, I always had the hope the long hours I spent at work would be less the further out of training I was and I would have more control over my schedule. Little Kathleen did I know with each additional child and more Eubanks-Meng, DO experience would bring a life tug of war with more Board Chair than two sides.

I was driving past the elementary school in my neighborhood on my way to work and noticed the school custodian had a new zero turn mower. I had thought of the many conversations I had with her about the old push mower and how much time it would save her to have a riding mower.

This led to thoughts of how I would really like her job today instead of my own. It was a beautiful sunny day and she had a new mower to enjoy it. Wait, I love my job as a family physician, yet I now want to give it all up to be a janitor? Maybe this physician burnout thing is more real than I thought.

By our nature, physicians are competitive. If we were not, we would not have made it through the rigorous training our profession requires.

However, what we are not trained for is how to compete and still win when our greatest competition is ourselves. Balance. We all have increasing demands of the evolving electronic heath record, quality measures, risk adjustment scores, For further resources per patient per month cost on burnout, please visit and expense analysis, and aafp.org; the transition of emphasis on payment for quality in helpguide.org; or thehappymdmembers.com a healthcare system that is geared towards fee for service. The rules will continue to change along with our paycheck. However, the debts do not change and at times feel insurmountable. There are not enough hours in a day to do our work, let alone live our life.

We are taught that sleep is a luxury not a necessity. Stress management is making another pot of coffee to press on. Exercise is when you get to move to the next patient room or walk up the stairs instead of taking the elevator. Emotions are not allowed because we must have our doctor shield of armor on or you may not be able to make it through telling a patient they have an illness there is no cure for. Nutrition is what is 4

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

available in the vending machine or the scraps that are left in the breakroom. Donuts and pizza never go bad, right? Biological rhythms are what we learned about in 8th grade science class with the different ecosystems, they don’t apply to us, we are physicians, not humans.

"

Every physician’s story and tug of war will look different. However, we all are on the same team with similar struggles.We all want to provide the best quality of care for our patients, but we also want to enjoy our families and what life offers."

Do you start a long road trip without a full tank of gas? I know I don’t. Every journey starts with a full tank. To be the caregivers, we must prioritize care for ourselves and fill our tanks.

This requires us to recognize that when we want to become a janitor and quit our job as a family physician, we may need to recognize self-care needs to take place. This may start by getting four hours of sleep at night instead of two, or six, instead of four, baby steps. It may mean you need to talk to a counselor or a colleague about your frustrations. It may mean taking a 10-minute walk at lunch without your phone or computer. It may mean closing the door so you can cry after losing a patient or to text your teenager you love them. It may mean meal planning for 30 minutes a week so you fill your tank with premium instead of quick mart gas. It may mean seeing one less patient a day, so you can have dinner with at least one family member. Every physician’s story and tug of war will look different. However, we all are on the same team with similar struggles.

We all want to provide the best quality of care for our patients, but we also want to enjoy our families and what life offers. Be aware of your surroundings, recognize the signs for yourself and for your colleagues. There are many resources available, but the real answer will start with you.

It is now past midnight and a 5 am alarm will come too early. I am still learning and making imperfect progress and I don’t intend to leave my job in family medicine.

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nm5001

Is Burnout Revealing Itself to You?

I Mark Schabbing, MD President

would like to take a minute and address the problem of burnout that we, in this medical career, are facing today. Burnout is not only a problem our physicians are facing today, but our support staff as well to include, nurses, medical assistants, and our techs are facing some of the same stressors we are dealing with each day. For family physicians, in 2011, burnout rates were just over 50%, and in three years had increased to 63%. The rate of burnout for all specialties combined was 45% in 2011 and increased to 54.4% as reported in an article by the AMA Wire. In a talk given by Deepak Chopra, MD, at this year's Family Medicine Experience (FMX), he stated that female providers were at increased risk for burnout. Studies show that 55% of women as compared to 45% of men have struggled with burnout in family medicine.

"

Burnout is not only a problem our physicians are facing today, but our support staff as well to include, nurses, medical assistants, and our techs are facing some of the same stressors we are dealing with each day."

Several studies have reported the main reasons for burnout can be directly linked to loss of control over work, increased performance measurements (quality, cost, and patient experience), the increasing complexity of medical care, the implementation of electronic medical records, and continued inefficiencies in the practice environment.

Burnout will typically reveal itself with these three typical symptoms: 1. Exhaustion - You wake up tired even though you have had a good night’s rest and are not interested in facing another day at the office.

This exhaustion could be from no energy, lack of emotion, or even spirit.

2. Cynicism - With cynicism, you have lost your ability to connect, to care, or empathize with patients, staff, and co-workers. This can lead to blaming the people we are in charge of caring for.

3. Doubt - This is a late symptom and rarely seen in men. Here, we doubt we are making a

6

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

difference or question the quality of our work.

Family doctors are uniquely at risk for burnout because of our self-sacrificing altruistic lifestyle.

We, as a group, are dedicated to our patients and frequently place their needs above our own good.

Why is burnout important? Burnout is becoming a crisis to the healthcare system at this time. Not only does burnout affect the physician but can lead to issues of patient safety, quality of care, and significant costs. A physician that is exhausted and not connecting with their patients is at risk of making mistakes. This may be revealed in medication errors, unnecessary referrals or testing, and malpractice issues.

Burnout can lead to early retirement or cutting back on time in the office. It has been estimated that replacing a physician may lead to $500,000 to $1,000,000 in lost revenue. And, worse case scenarios, burnout can lead to depression and even suicide.

The AAFP recognizes this growing problem in family medicine and the effect it is having on our members. It is moving forward with a new initiative, Physician Health First, that was recently kicked-off at FMX 2017. Physician Health First is a portal that we can enter through the AAFP website. It will contain an inventory to evaluate you for burnout, and will be linked to information and a blog that can be helpful in keeping us on track.

In addition, the AAFP is sponsoring a Wellness Conference in Naples, Florida next year, April 18-21, 2018. The AAFP is advocating for us to reduce senseless prior authorizations, and other paper work that takes us away from doing what we are called to do, which is care for our patients.

I would like to invite you to come to our fall conference at Big Cedar Lodge this fall and if you are struggling with some burnout, enjoy the beautiful scenery and relaxing atmosphere of Southwest Missouri and reconnect with your colleagues from across the state!

We are dedicated to rural and underserved areas of our great state! MHPPS partners 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 se�ng, dynamic urban loca�on, or somewhere in between, we are commi�ed to focusing on your interests and careers that count!

Find Out More: Contact Us Today!

Joni Adamson Manager of Recruitment 573.636.4222 jadamson@mo-pca.org www.3rnet.org/missouri

Opportuni�es t�roug�out our Rura� � Ur�an Areas:  �oan Repayment Op�ons  Compe���e �a�ary � Compre�ensi�e �ene�ts  Team �ased Mode�s of Care / Care Coordina�on  �i��e or no Ca�� / Mo�ing A��owance / �igning �onus

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MHPPS is non-profit and located within the MO Primary Care Associa�on MO-AFP.ORG 7

burn

burn¡out

noun: burnout; noun: burn-out

1. physical or mental collapse caused by overwork or stress.

n¡out "female physicians reported a higher prevalence of burnout 55% than their male counterparts 45%, although both genders have seen a steady increase since 2013 (45% and 37%, respectively)."

Source: AAFP, Family Practice Management

P

hysician burnout has been a consistent area of concern for decades. Burnout not only negatively impacts the quality of patient care, but also results in physciains leaving their practice, thus contributing to the primary care workforce shortage.

The American Academy of Family Physicians (AAFP) conducted studies indicating common drivers of family physician burnout: paperwork; feeling undervalued; frustrations with referral networks; difficult patients; medicolegal issues; and challenges in finding work-life balance. These factors have varying impact at different stages of a physician’s career, with inability to resolve work-

life conflict having the greatest impact for physicians early in their careers. Long hours, frequent calls, frustration with administrative burden, and reimbursement issues strongly impact physicians in the middle of their careers.

Burnout impacts physicians across all specialties. In this issue, we hope to educate you on identifying the root causes of burnout, learn personal resiliance skills, and ways you may be able to take a systems-based approach to identifying and combating the causes of physician burnout. You will read stories from actual physicians, residents and students on how they battled or continue to battle the burnout burdens in their lives.

MO-AFP.ORG 9

Reclaiming Peace of Mind in Healthcare: Preventing Burnout

B James Wieberg, M.Ed, LPC Director, Capital Region Medical Center, Jefferson City

urnout, first defined in the 1970’s, is a phenomenon based on three main factors: emotional exhaustion, depersonalization and a low sense of personal accomplishment. Work, formerly a source of gratification, becomes difficult, burdensome and often meaningless.

Depersonalization refers to a state of cynicism and detachment people assume in order to emotionally distance themselves from their work. Lastly, victims of burnout feel ineffective, exhausted and utterly hopeless; experiencing what has been referenced as “erosion of the soul”.

"

Practitioners of family medicine, general medicine, and ER medicine are at the highest risk."

It appears that those at mid-career are more often on call, work longer hours and compared to their other colleagues are less satisfied with their choice of specialty and their work-life balance and have higher burnout rates. A most recent study (Mayo Clinic) shows that close to one out of every two physicians has reported signs of burnout. Practitioners of family medicine, general medicine, and ER medicine are at the highest risk.

Sources of the problem appear to be three-fold: intrinsic, extrinsic, and individual factors. The intrinsic factors refers to the main elements of a physicians’ work, this includes elements such as intellectual rigors, the burden of decisionmaking, stress levels due to uncertainty and emergencies, and being confronted constantly with suffering and death, along with problematic interactions with certain patients. Although the patient-physician relationship is at the heart of the medical profession and is one of its most gratifying aspects, it can also represent, in emotional terms, one of its heaviest burdens.

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MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

Extrinsic factors refer not to medical practice itself, but rather to how it is organized: schedules, workload, environment, autonomy etc. These factors often lead physicians to have to choose between addressing the practice requirements and compromising gratification in their personal lives. Many physicians come to believe that they cannot simultaneously be fulfilled personally and professionally, and must therefore put their personal lives on hold until retirement. One study (Langballe) indicated that work-home conflict is the strongest burnout predictor in female physicians, whereas workload is the strongest burnout predictor in male physicians. Another factor is the incongruence of their individual values with the values in their workplace contributes equally and independently to burnout, especially for female physicians.

Individual factors contribute to burnout as well. For example, people who do not worry are immune to burnout. Certain personality traits put people at a higher risk of burnout. Perfectionism, a characteristic that is sought after and valued among physicians, generally goes hand in hand with exceptional levels of dedication and professionalism. However, this characteristic can also present in a dysfunctional and rigid manner, and give rise to an urgent need to control one’s environment and over commit to work. Self denial and altruism, so valued by the medical culture, may represent serious risks to physicians’ health and stability, and impede their ability to deliver quality care to others. One of the tragic paradoxes of burnout in medicine is that those who are most susceptible also appear to be the most conscientious, responsible, and motivated.

Consequences: Faced with constantly growing demands, physicians naturally seek to absorb their excessive workload by doing even more, regardless of their health and job conditions. The culture of endurance forces them to keep going, despite organizational deficiencies or personal problems. In addition to contributing to family and marital tensions, burnout is associated with an array of somatic symptoms such as heart conditions, perturbed sleep patterns and anxiety, and may lead to depression, substance abuse and even suicide.

The language we hear in our clinic from burned out practitioners is “I can’t stop the pain”, “I can’t think clearly and can’t get control”, “I can’t make decisions and can’t see any way out”, “I can’t make the sadness go away”, “I can’t see a future without pain”, “I can’t see myself as worthwhile”, and “I can’t get anyone’s attention”. What others say about the burned out practitioner is the person appears “more tired”, “Irritable”, “can’t concentrate”, “can’t seem to make decisions” and is “losing weight”. Usually the last person in the room to recognize either the burnout or its severity is the burned out practitioner.

So what can a physician do to deal with the intrinsic, extrinsic and individual factors that contribute to burnout? Start by practicing good stress management practices. Preserve some of your energy pie every day for family and friends. Elicit unconditional support from your spouse/partner. A “sine qua non” is daily exercise.

Establish regular sleep habits. Be aware of your nutritional intake. Continue to develop your spiritual life with quiet time, meditation, and mindfulness daily.

Don’t forget about your hobbies and reestablish them if you have forgotten them. Practice acceptance over those issues which you have no control. See your own healthcare provider regularly. Avoid the “psychology of postponement”.

"

Continue to behaviorally support what you say you personally value, even when the pressure is there to compromise. Finally, physicians need to look out for each other.

Preserve some of your energy pie every day for family and friends."

A statewide resource that is open to all physicians and allied health practitioners and students is your Physician Health Program who can provide helpful resources. For example, the Physician Health Program has been providing remedial resources to the medical population in Missouri since 1987. To make contact, call 573-632-5562: Heather Johns, Associate Director, Jim Wieberg, Director, or Dr. Russ Carpenter, Medical Director, are available to help you address your needs.

Reference books: “How to Survive in Medicine: Personally and Professionally” Jenny Fifth-Cozens “The Resilient Physician: Effective Emotional Management for Doctors and their medical organizations” Wayne M. Sotile, “Staying Human During Residency Training” Allen D. Peterkin MD, “Iron Doc: Practical Stress Management Tools for Physicians” Mamta Gautam.

MO-AFP.ORG 11

Faith and Family Life Help Stave Off Burnout; "Medicine is My Calling"

W

hen Stephen Dudley, M.D., swims in Puget Sound year-round, he's not just swimming. As he slices through the water, he's also praying. Just as the Olympic Peninsula protects Puget Sound from the sometimes-violent weather of the Pacific, Dudley's faith and his family life help protect him from burnout. Dudley recently shared with AAFP News how faith has helped him chart the course of his life and be a balanced, productive physician.

"

First and foremost, my faith grounds me and gives me perspective. When things are stressful at work, I know this isn't all there is in the world."

Q. How have your religious beliefs and practices sustained you and helped you stave off burnout?

A. I grew up in an Episcopal home, and I've never not believed in God or felt religion wasn't important. But in the 1970s, at the height of the Jesus movement, my spiritual life reawakened.

I realized it wasn't just a Sunday thing, but something that influences my entire life.

First and foremost, my faith grounds me and gives me perspective. When things are stressful at work, I know this isn't all there is in the world.

I believe that life on earth is a training ground for an eternity spent with God, and if there's an unpleasantness along the way, it's calming and reassuring to know it's happening for a purpose.

Is it to teach me something -- like patience and humility? I try to analyze my life and see if I can correct the way I behave.

Spending time with family is a must for Stephen Dudley, M.D., shown here during a trip he and his wife, Gabrielle, took to Turkey, the Greek islands and Spain in 2015. This particular island, Santorini, was known as Thera in ancient times and was the site of a catastrophic volcanic eruption during the mid-second millennium B.C.

Family physician Stephen Dudley, M.D., of Shoreline, Wash., is arguably a true Renaissance man.

In addition to his strong religious faith, devotion to family and appreciation for the rigors of exercise, Dudley has a passion for the written word. Here are a few articles he's written for the Los Angeles Times: Dear Parents: Why Vaccines are Vital; Concierge Medicine Has a Cost for All Patients; and Respecting a "Non-compliant" Patient's Choices.

I'm usually the first one up in my house, and I try to start each day reading my Bible and having a time of prayer and meditation. Some long stretches in the Bible don't speak to me, but other places I've read 20 times, often with something different jumping out at me because I've changed or I'm experiencing a new situation.

Stephen and Gabrielle enjoy a hike along Snow Lake Trail near Snoqualmie Pass in the Cascades.

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MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

I believe that medicine is my calling, and when I read stories in the Bible about people with a strong sense of vocation and a calling, it inspires me. I get a lot of inspiration from Dr. Luke, a physician who was one of Jesus' closest associates.

I especially like the epistles of St. Paul, who I think was the deepest Christian thinker who ever lived. He was steeped in the Jewish faith and quite antagonistic toward Christians until he had a life-changing experience with Jesus on the Damascus road, and then he became the faith's strongest advocate. When I read his epistles, I get a sense of someone who is gifted in understanding of theology but who also has the most tender heart toward others.

"

If at all possible, establish your own internal barometer of what you're willing to put up with and how long you'll put up with it."

And he was under tremendous stress. He wrote Philippians, the eleventh book in the New Testament, while in prison waiting to have his head lopped off by Nero. That's an amazing book -- he says, "I can do all things through Christ who strengthens me." It's hard to read St. Paul and not get something out of it.

I sometimes pray on my way to work, and when something stressful happens at work, I may pray silently. And then I pray while swimming in Puget Sound. I don't have to count laps and the motion is repetitive, one arm in front of the other, so I can get into a rhythm and pray.

Religious traditions and church services also speak to me. I'm there with others from different walks of life, and we're all singing the same songs and coming together in unity.

Q. You've said that a rich family life is important to combating burnout.

A. It is indeed. I wanted to marry someone who shared my faith, and fortunately, I found that someone: Gabrielle. We'll have been married 35 years this fall. She helped support me through four years of college, four years of veterinary school, four years of medical school and three years of residency. I always let her know how much I appreciate her!

When I was in med school, we had two small children. I would sometimes leave labs early and pick up the kids, then study between their naps.

During residency, when my days on call ended at noon or 1, I'd pick them up from school and spend time with them. I could have learned a little more in medical school and residency, but I wasn't going to grow up not knowing my kids.

They're now 27 and 29 and seem to think I'm an OK guy, and my son is a fourth-year medical student.

I've long felt that the training process to become a physician is too onerous. You won't find any other career where the time demands are similar. Medicine selects for the test-takers and people who can remember arcane minutiae, and that doesn't necessarily translate into a good physician.

I would love to see a system where residency training doesn't try to cram in so much information, and graduates go into practice with mentors for a few years. I had that after vet school, practicing with eight vets who were the most supportive professionals I've ever worked with. One in particular -- a dairy vet -- was the kindest, gentlest guy who didn't treat me like an idiot for asking questions. I remember him even after 25 years, and I emailed him recently to let him know I'm doing well.

Q. Have you ever experienced burnout?

A. I may have, early in my medical career. I was working all the time and had no control over my schedule or anything. I found I dreaded going to work each Monday, so I resigned and cobbled together some part-time urgent care jobs for a few years.

Then I joined a small independent practice for 11 years. Toward the end, it was increasingly challenging because of the extra burdens placed on private practices.

continued on page 14...

MO-AFP.ORG 13

continued from page 13...

About that time, my wife was diagnosed with advanced ovarian cancer. Believe me, that reinforced the point that there is more to life than going to work! Happily, she's in remission right now, but it's been a roller coaster. I knew it would be hard to take time off if I needed to, so I left the practice and became an employed physician at the University of Washington Neighborhood Clinic, Ballard Urgent Care. I've given up some autonomy, but in return I'm working for an organization with better health insurance so we don't have to worry about untenable medical costs, and I have leave time I can access. That's a huge stress reliever.

Q. Do you have mentors in medicine who help you cope with stress and avoid burnout?

A. My wife is my greatest mentor and counselor.

Unfortunately, there aren't key peers in medicine that I can go to when things get tough and I'm stressed. It's just not something that is discussed, which makes me sad. Even in my first practice, with Christian doctors as partners, we didn't really talk much. We focused on seeing patients, charting over the lunch hour and at day's end, then racing home to our family lives. No one got down and real about what they were going through in their lives.

Q. What advice would you have to help family physicians avoid burnout?

A. If at all possible, establish your own internal barometer of what you're willing to put up with

and how long you'll put up with it. Some people think that after residency, it will be smooth sailing.

After residency, they think it will happen once the first five years in practice are done. And then they think it will happen when the house is paid off. But when you maintain a frenetic pace, you establish a pattern. So definitely cultivate some time for other interests. They're necessary!

It's important for your work to have purpose, because if work loses its significance, that quickly affects the spirit. I don't mind long days if I can use my skills appropriately. However, when simple tasks tend to dominate -- such as getting the minutiae of coding just right to satisfy the billers -- that can wear me down. I try to focus on the fact that I am about the Master's business. It's my calling. I don't work for the University of Washington, insurance companies or patients, but rather, I see myself as being in the service of the King. It gives gravitas to even the most mundane tasks.

If you've tucked your spiritual life away, unpack it and try it on again. Some people turn to meditation and yoga to avoid burnout, and those could help, but also try rediscovering your faith. It might be just what you need.

AAFP News, August 16, 2017. Š American Academy of Family Physicians; Author: Chris Crawford

ARE YOU SEEING SIGNS OF BURNOUT?

LET US HELP YOU HelpGuide.org

helpguide.org HelpGuide's mission is to provide research-driven, impartial tools and information to help readers strengthen their mental and emotional health, improve their relationships, and take charge of their lives. HelpGuide now serves over 65 million people a year– free to all, and free of advertising or corporate influences.

The Happy MD

thehappymdmembers.com The Happy MD offers a set of field-tested resources to help prevent physician burnout and build an ideal practice along the way. Register (no charge) and get instant access.

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MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

StressRemedy.com

stressremedy.com StressRemedy.com provides fourteen guided meditation exercises aimed to decrease stress and increase health and well-being, as well as resources to aid in improving office efficiency to reduce burnout.

Why Don't We Take Care of Ourselves?

I

t was difficult to locate a lot of research on general physician health. There are a number of articles addressing physician burnout along with the depression, and sometimes, suicide that results from burnout. However, it is difficult to find statistics on how many physicians regularly see a personal physician.

"

As difficult as it is to be a physician patient, it is also difficult to be the physician’s physician."

We very seldom take sick days. This is related to both psychological and organizational factors.

We know how hard it is to find someone to cover for us, and if we don’t, our patients will all have to be rescheduled. The responsibility we feel for our patients may trump the need to take care of ourselves.1 We often go to work sick, exposing our co-workers and patients to potentially contagious diseases. If it gets really bad, we may swipe something from the sample closet or call in a prescription for ourselves. In fact, studies have shown that anywhere from 52-90% of physicians have self-prescribed or otherwise rendered treatment for themselves.2,3 Getting away from your own office to go sit in someone else’s office waiting for your own appointment may seem like a waste of time when you can simply treat yourself. It is much easier to grab a colleague in the hallway and “curbside” if we cannot take care of something ourselves. In this case, neither the patient nor the consulted physician are following the norms for an office visit. The exam may be inadequate or completely lacking because of the setting.

But what about things like hypertension, high cholesterol, diabetes, or any of the other chronic conditions that we take care of day in and day out? After all, if it is what we would do for our patients, shouldn’t it be what we want for ourselves? However, there isn’t that objectivity that comes from having someone else evaluate, diagnose, and make recommendations. We may be prone to treat beyond our expertise and training. Lest we forget, it is also difficult to do a physical examination on ourselves.

The American Medical Association’s Code of Medical Ethics states, “Physicians generally should not treat themselves or members of their immediate families.”4 The exceptions are in cases of emergency, but some state laws do prohibit self-prescribing and it can also run afoul of state pharmacy statutes. Controlled substances are most likely to be prohibited, but in some states, this pertains to any self-prescribing.2 Insurance companies may not cover the cost of prescriptions when self-prescribed either.

So why are we so bad at taking care of ourselves? We may keep from seeking care from a colleague out of fear of being turned away or being a bother to another physician. There is also a fear of exposing our weaknesses and plain old denial that there is anything going on.5 This denial, along with associated anxiety, may blur accurate symptom self-evaluation. We also tend to minimize or intellectualize symptoms leading to

delays in diagnosis and treatment.1 Privacy is a concern even though our treatment is supposed to be confidential.6 There is still a risk that staff may recognize us or have access to our records. If we are already anxious about seeing a colleague, will we be as forthcoming with potentially sensitive history if we are worried about the confidentiality of our medical records?

An issue unique to physicians is the requirement to disclose health issues to our state Board of Healing Arts. We all know about the requirement to disclose any alcohol or drug use.

There are also questions about any treatment for bipolar disorder, schizophrenia, paranoia, or any other psychotic disorder in the past ten years.

We are also asked about any current “medical condition or disorder that limits or impairs our judgment or that otherwise affects our ability to practice medicine in a safe and competent manner.”7 The Missouri application goes on

Kate Lichtenberg, DO, FAAFP

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to state that “If your answer is ‘yes,’ provide complete details and dates, including the names and addresses of individuals who treated you and any hospitals/institutions where you have been treated on a separate notarized statement.

The Board also requires a letter from your treating professional indicating your diagnosis, prognosis, and if your illness or condition affects your ability to practice.”

If you choose to practice in another state, the questions vary. A 2009 study in Academic Medicine found 96% of all medical license applications contained questions pertaining to the physical health, mental health, or substance abuse history. Sixty-nine percent of those applications contained at least one “likely impermissible” or “impermissible” item based on the Americans with Disability Act of 1990 and appropriate case law.8 Given all of the attention being given to physician burnout and the depression and anxiety that may accompany it, physicians are put in what can seem like a no-win situation. Mental health is already stigmatized and there are many barriers to seeking and receiving treatment. If physicians fear referral to their Physician Health Program or having limitations placed on their license, they are even less likely to seek care.

It is clear there is a need to find strategies to assist physicians in obtaining care. As difficult as it is to be a physician patient, it is also difficult to be the physician’s physician. Insecurity of the treating physician may lead to unnecessary studies and exams. It is easy to slip into medical jargon and not offer all of the information that may be given to a “regular” patient. Having a patient that knows everything that can go wrong in the hospital makes all involved anxious. In Norway, a group of physicians are trained by the Norwegian Medical Association specifically to care for other physicians.1 Other novel and innovative ideas need be explored for providing care to physicians.

In addition to all that we read in medical publications, patients are becoming more aware of the toll of our poor health. An article from Time in 2015 reports up to half of all physicians are burned out. The rate of medical errors and suboptimal care is increased, and as many as 400 physicians a year commit suicide leaving thousands of patients with no physician.16 The American Academy of Family Physicians has recently launched “Your Health Before All Else.” There are numerous resources available on the AAFP website including solutions to well-being, tips on improving your health and 16

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professional satisfaction, and the Maslach Burnout Inventory. AAFP is also sponsoring its first Family Physician Health and Well-Being Conference in April 2018. More details can be found at http://www.aafp.org/membership/ benefits/physician-health-first.html.17 If it has been years since your last visit to your own family doctor, make some time. If you are feeling overwhelmed and burned out, reach out to a friend. Our patients are counting on us to take care of ourselves so we can be there for them.

References: 1 Rosvold EO. “Doctor, Don't Treat Thyself.” Agency for Healthcare Research and Policy, Patient Safety Network. 2014 September, psnet.ahrq.gov/webmm/ case/71. Accessed 25 August 2017.

2 Adler EL.“Physicians and Self-Prescribing: Just Say ‘No.’” Physicians Practice. 21 December 2011, www. physicianspractice.com/blog/physicians-and-selfprescribing-just-say-%E2%80%98no%E2%80%99.

Accessed 25 August 2017.

3 Latessa R, Ray L. “Should You Treat Yourself, Family or Friends?” Family Practice Management.

2005 Mar;12(3):41-44. www.aafp.org/ fpm/2005/0300/p41.html. Accessed 25 August 2017.

4 The AMA Code of Medical Ethics’ Opinion on Treating Family Members. Virtual Mentor. 2012 May; 14(5): 396-397. journalofethics.ama-assn. org/2012/05/coet1-1205.html. Accessed 25 August 2017.

5 Ladouceur R. “Should doctors treat themselves or not?” Can Fam Physician. 2009 Aug; 55(8): 776. www.ncbi.nlm.nih.gov/pmc/articles/PMC2726086/.

Accessed 25 August 2017.

6 Johnson K. “Against Recommendations, Physicians often treat themselves.” 31 October 2012, Medscape Medical News from the 2012 AMA/CMA/BMA International Conference on Physician Health. http://www.medscape.com/ viewarticle/773623#vp_1. Accessed 25 August 2017.

7 Missouri Board of Healing Arts Physician License Application. Missouri Division of Professional Registration. pr.mo.gov/boards/healingarts/375-0457. pdf. Accessed 31 August 2017.

8 Schroeder R, Brazeau CM, Zackin F, Rovi S, Dickey J, Johnson MS, Keller SE. “Do State Medical Board Applications Violate the Americans with Disabilities Act?” AAcad Med. 2009 Jun;84(6):776-81. doi: 10.1097/ACM.0b013e3181a43bb2. Accessed 11 September 2017.

9 Oaklander M. “Doctors on Life Support.” Time Health. 27 August 2015, time.com/4012840/doctorson-life-support/. Accessed 25 August 2017.

10 Physician Health First. American Academy of Family Physicians. www.aafp.org/membership/ benefits/physician-health-first.html. Accessed 11 September 2017.

students

what about the students?

Yoga, Volunteerism Help Medical Student Battle Burnout

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edical students are no strangers to burnout. Anna Askari, a fourthyear medical student at Ohio State University College of Medicine in Columbus, says she's often felt burnt out. Now, fresh from completing the demanding United States Medical Licensing Exam Step 2 Clinical Skills Exam, Askari talked with AAFP News about how she copes with stress and burnout and how she plans to manage it as a resident and beyond.

Q. Can you share with me when you've experienced burnout during medical school?

A. I think I really noticed it toward the end of the school year during my first year of medical school and then again during my second year when I was studying for my first board exam. That was a particularly stressful time. In my third year, too -- with our rotation schedules, you're not only kind of working a full-time job, but you also have to come home and study. I felt burnout at the end of third year, as well, when I was studying for my Step 2 Clinical Knowledge Exam, which I took about a month ago. When I realized I was experiencing burnout again, I took some steps to better help myself, and I feel like my Step 2 experience was better than my Step 1 experience.

Q. What do you do to manage burnout?

A. Yoga has been really helpful. We had an older classmate, Dr. Liz Maxwell, who is now a family medicine resident. She was a yoga instructor before medical school. When she came into the medical school environment, she realized how stressful it was, and she decided to create a yoga class for medical students once a week that she taught for free. It was fantastic. She would be on her third-year rotations and tell us little stories about her patient experiences. As a first- and second-year, I thought that was really fun.

I definitely use yoga not only as a way to exercise, but also just to be mindful, to take deep breaths. As medical students, most of us are Type A personalities, and we have this guilt when we're not doing something school-related. That takes

Anna Askari is a fourth-year medical student at Ohio State University College of Medicine in Columbus who has already experienced symptoms of burnout.

"

away from any rest period that you need to give yourself. Yoga forced me to think about myself and take that time.

Yoga forced me to think about myself and take that time."

I think it's important for medical students to take themselves out of the stress of medical school and reflect on why they went to medical school. It was fun, going to Ohio chapter meetings from time to time and seeing my future colleagues and mentors. It puts into perspective why I want to go into family medicine, how important our work is, and how much work we need to do to advocate for our patients. Askari says her advocacy activities are one of a number of tactics she uses to fend off stress and restore perspective.

Another thing for me is my free clinic work. It was something I did before medical school and it was a big reason why I went into medicine. During my second year, I was the volunteer coordinator

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at one of the free clinics, Noor Community Clinic. That was a good leadership position to have and it was something that helped me keep perspective on why I went to medical school.

Now, as a fourth-year medical student, I have the opportunity to complete one of my rotations longitudinally at the Helping Hands Free Clinic. It's a really good way for me to realize, "OK, I'm doing this, I'm learning all of this so I can see patients."

As much as it might seem like it's more work, for me it was a great relief. It was an extracurricular activity that gave me perspective on why I am doing this.

I also feel that spending time with family and friends is really good, too. I hang out with my medical (school) friends, but nonmedical school friends are fun to hang out with because they're not going to be talking about anything medical school-related. It's really nice to not have to think about the part of your life that's really taking over your life.

"

Every student graduate, professional, undergrad - is given 10 free counseling sessions per academic year. I've utilized that all four years of my undergrad as well as my four years of medical school."

Q. How has your medical school promoted student wellness and mental health?

A. We are really lucky at Ohio State to have Dr. Linda Stone. She is also a family physician, and she's in charge of the Humanism in Medicine Program. We have everything from groups like Dance in Medicine to an orchestra that (includes) medical as well as dentistry and pharmacy students. We have a lot of arts organizations.

I was involved in a book club during my first and second years of medical school. We'd read a book (or) an article, and then come together, have some dinner and discuss it. Usually these articles or books were things like The House of God (www.

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amazon.com). It was first- through fourth-year medical students, and sometimes residents and attending physicians, that would join us. It's just another example of taking care of yourself.

At Ohio State, every student -- graduate, professional, undergrad -- is given 10 free counseling sessions per academic year. I've utilized that all four years of my undergrad as well as my four years of medical school. Especially in medical school, I felt it was helpful to meet with someone outside of school. I would meet pretty regularly with her. When I felt burnout was occurring, especially at the end of school years, I would meet with her a little bit more.

If you need help more immediately, we have a psychiatrist specifically for our medical students.

If you feel like you need medication or counseling referrals, he would be available. I had a lot of classmates adjust their depression medication dosages for medical school just because it got more stressful. It's something that comes with the territory. It's going to be a stressful tough time, a lot of competition and material to get through.

It's important to have support from mental health professionals. It's also a really good practice as a future family physician to be able to talk about how we've utilized mental health services and normalize it for our patients.

Q. Are burnout and mental health something you talk about with your peers?

A. Yes, we definitely do, especially during a tough course or something like the Step 1 Exam.

We also have had a lecture from one of our professors. He did a specific talk about burnout with statistics to inform us that it's an issue nationally and across specialties. He talked about how it starts in medical school and how building good habits and doing the things that keep you sane and level are important. As you're going into residency and your career, it's not necessarily going to get any easier.

Q. How do you plan to manage your own wellness as you launch your family medicine career?

A. I am really interested in direct primary care (DPC). DPC has all the elements that I think are important for me to prevent burnout -- from not working with insurance companies to having more time with your patients per appointment and being more available to your patients. I feel the kind of robotic work that some physicians unfortunately are forced to do -- having 15-minute appointments to get a certain volume to get paid enough to continue practicing -- is really stressful.

Also, I'll be continuing advocacy work. I think it's so important to come together with other

"

I think it's just important to enjoy medical school as much as you can. It goes by fast, (even though) it may feel like, especially during burnout time, it's going so slowly, almost torturously slow. It's something that all of us dreamed of at one point or another, so keep that perspective in mind that it's going to be worth it in the end."

physicians with different practice styles, all dedicated to family medicine, patients. Advocacy becomes more meaningful when other parts of our job, like filling out (electronic health record) notes, become tedious and stressful.

Q. Will you continue your free clinic work?

A. Yes, for sure. That's actually a really big career goal of mine, too.

Q. What advice do you have for other medical students?

A. Take advantage of mental healthcare professionals. There were high-stress times when I thought, "OK, this is going be a really tough time, I need to talk about this," and she would be someone who would check in with me. Hopefully, other medical students have that as an option.

I think it's just important to enjoy medical school as much as you can. It goes by fast, (even though) it may feel like, especially during burnout time, it's going so slowly, almost torturously slow.

It's something that all of us dreamed of at one point or another, so keep that perspective in mind that it's going to be worth it in the end.

Do those extracurricular activities that work for you. Whatever it is that you're particularly passionate about in medicine will help you stay sane during a time when it's probably OK not to feel so sane.

AAFP News, July 19, 2017. Š American Academy of Family Physicians; Author: Chris Crawford

residents ...and the residents?

Resident Confronts Burnout by Launching Wellness Program s the AAFP takes on the challenge of combating professional burnout and cultivating physician wellness, Kristina Dakis, M.D., a second-year resident in the University of Illinois at Chicago (UIC) Family Medicine Residency Program, recently gave AAFP News an inside look at her own experience with burnout early in her medical training and explains how it drove her to help create a medical student wellness program to combat it.

A

Dakis

"

It's important to realize that burnout is a huge problem in physicians-intraining long before they ever enter an exam room." continued on page 20...

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"

Based on recent studies, 50 percent of medical students will burnout at some point during their medical training; 25 percent will become depressed; and 10 percent will experience suicidal ideation. Clearly, the problem isn't only the electronic medical record something is wrong with the way we train physicians, and we should be talking more about it."

20

Q. Can you start by explaining the wellness program you worked to create at your medical school and your goal in doing so?

A. I was the co-founder of our medical student wellness program during my third year of medical school at the UIC College of Medicine. The program consisted of a medical student-led wellness committee with representatives from each medical school class, and we worked closely with the office of student affairs and medical school faculty from different departments who were committed to student well-being. Our program consisted of four main components.

First, we initiated an extracurricular series of wellness events that included a physician panel to talk about their personal experiences dealing with burnout in medical school and ways they overcame their burnout, a panel of psychologists who discussed ways to overcome test anxiety, massage chairs, therapy dogs, yoga sessions led by students, etc.

Second, we started a monthly support group for medical students. This was hosted by our faculty adviser Memoona Hasnain, MD, MHPE, PhD, who invited us into her home and served us chai tea. We called them "Chai Chats," and we discussed common challenges in medical training, in addition to ways we find joy in our work.

The third component was meeting with faculty to discuss ways to potentially incorporate wellness into the medical school curriculum. We hosted one of our school's first-ever mandatory wellness events during the M1 orientation -- a panel of upperclassmen who discussed their own experiences with burnout as M1s. This not only normalized burnout for students, but gave them an opportunity to hear ways to prevent burnout during their first year of medical school.

Finally, the fourth component was research to evaluate the effectiveness of our programming.

Q. What progress has the medical school made since incorporating the wellness program?

A. I am proud to say UIC has started implementing a four-year wellness curriculum that includes interactive presentations by medical school faculty on test anxiety, burnout prevention and available mental health resources. One of our deans is currently piloting online, on-demand "wellness

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

modules" for medical students that teach the basics of cognitive behavioral therapy.

The wellness committee that we started remains strong. I am in touch with the current student leaders, and they host monthly wellness events for students, continue to get together at Dr. Hasnain's home for chai tea and remain invested in the development of the medical school wellness curriculum.

Q. I understand you've been involved with Family Medicine for America's Health (FMAHealth) (fmahealth.org). How did that come about?

A. Recently, I was a part of the FMAHealth Workforce Education and Development Team.

I worked with Joseph Brodine, who is a recent graduate of Georgetown University School of Medicine and our student leader, as well as with Natasha Bhuyan, MD, of Phoenix, and Christina Kelly, MD, of Fort Hood, Texas, who were our project advisers.

When our project began, the medical community was talking a lot about physician burnout, but not necessarily medical student and resident burnout. Our goals were to raise awareness about burnout specifically in medical training and to normalize discussion of mental health issues in the medical profession.

Much of our project involved hosting "wellness workshops" at different family medicine conferences during the year. We hosted three workshops at last year's National Conference of Family Medicine Residents and Medical Students, where Joe and I shared our own experiences with burnout in medical training, discussed national data, and then encouraged students and residents to open up and discuss their own experiences with one another. It was extremely well-received.

Students and residents were eager to share and to support one another.

At the conclusion of the workshop, we asked participants to discuss what they liked about their institution's wellness programs (if they had one), what could be improved, and what they could personally do to improve wellness at their medical schools and residencies.

During the rest of the year, we presented outcomes from the student and resident workshop to faculty at other family medicine conferences, including the AAFP's Program Directors Workshop and the Society of Teachers of Family Medicine Annual Meeting.

We then gathered data from faculty regarding what they had tried to prevent

For Kristina Dakis, M.D., who considered a career in music education before deciding to pursue family medicine, playing clarinet in a jazz band offers respite from the rigorous demands of medical training.

burnout in their trainees, barriers they have faced to achieving learner wellness and possible solutions.

It's been eye-opening to be a part of these discussions with students, residents and faculty from around the country.

Everyone is clearly committed to improving well-being in medical education, but there are still systemic barriers at play that we need to overcome before we can improve the medical school and residency experience.

Q. Why is it important to address burnout at the medical school level?

A. In the practicing physician community, everyone talks a lot about the electronic medical record, the mountains of paperwork and other administrative burdens that lead to burnout. While I agree that these things are a significant problem and need to be fixed, it's important to realize that burnout is a huge problem in physicians-in-training long before they ever enter an exam room.

Based on recent studies, 50 percent of medical students will burnout at some point during their medical training; 25 percent will become depressed; and 10 percent will experience suicidal ideation. Clearly, the problem isn't only the electronic medical record -- something is wrong with the way we train physicians, and we should be talking more about it.

In addition, some preliminary studies suggest that medical students who burnout during the process are more likely to choose fields with more flexible schedules -- that is, not primary care.

Personally, I believe burnout in medical school leads to a loss of empathy and therefore deters medical students from choosing careers in primary care. This is potentially a significant workforce recruitment problem.

The medical education community needs to be working together to train physicians who are mentally healthy and excited for their future careers. This involves decreasing stigma of mental illness, creating a culture that is collaborative and not competitive, and ultimately changing the culture of medical education.

The AAFP has made medical student and resident wellness a priority, and I am very grateful for the work AAFP leaders are doing to address this important issue.

Q. Can you give examples of burnout that you experienced and discuss how you dealt with it?

A. One month into my residency, my father was diagnosed with colon cancer, and suddenly my life was a lot different than I'd imagined it would be.

Toward the end of my intern year, I was having a difficult time empathizing with patients and found myself getting easily frustrated with them. I was emotionally exhausted all the time.

I had forgotten a lot of the reasons I'd fallen in love with family medicine in the first place. In fact, I found myself resenting medicine for keeping me away from my family. But there were three main things that helped me get through this.

The first was stepping away from work and focusing on family.

When my dad was getting really sick, I turned to my support network (family, friends, co-residents/colleagues). My residency program let me take as much time off as I needed. Because of this, my husband and I were able to have a last-minute wedding ceremony so my father could be there. I was also able to surround myself with people who cared about us and who reminded me of who I was outside of medicine -- which I hadn't thought about in a while. That was really important.

Another thing that helped me was reflecting on why being a family medicine physician makes me so happy. A very powerful experience I had as an intern was delivering my very first continuity OB patient. I followed her through her entire pregnancy. I really loved her. And I remember rushing to the hospital at 11 p.m. and having the entire family cheer when I showed up in the room. It's still amazing to me that I was the one to hand her child to her right after he was born, and that he is now my patient. It's just really beautiful ... and it made me realize all the potential patients out there who I might get to help one day, people I haven't even met yet. And that really makes everything worth it.

Finally, I dived into my FMAHealth project. Because it's sometimes way too difficult to stay human while in medical training, and I wanted to help raise awareness and do something about it. Trying to make a difference in my own small way was therapeutic for me.

Q. In closing, if burnout is seriously addressed at the medical school level, what does that mean for future generations of students?

A. Medical students would be encouraged to seek help for mental health conditions when needed -- in fact, they would be praised for taking extra time to care for themselves in order to be mentally fit to serve their patients.

Medical students would find more joy in their work, make self-care a priority and -- in my opinion -- would be more likely to choose careers in primary care.

This kind of learning environment would foster a happy, resilient physician workforce prepared to address the healthcare needs of our country.

I am encouraged by the tremendous progress we have made over the past few years to address this issue, and I cannot wait to see what other positive changes we can make in medical education.

MO-AFP.ORG 21

National Conference National Conference of Family Medicine Residents & Students

22

Missouri Delegates Active at NCFMRS

M

issouri’s two delegates were among the 1,144 residents and 1,655 students who attended this year’s AAFP's National Conference of Family Medicine Residents and Medical Students held July 27-29 in Kansas Jacob Shephard, MD City. Missouri had 80 registered attendees participate in this three-day conference. Many of these residents wrote and discussed resolutions on patient care, advocacy and residents' needs as participants in the 2017 Congress.

"

I also had the opportunity to vote on resolutions.

This was a great experience because the Congress of Residents business sessions were formal and gave me a taste of what it would be like to work in a congressional setting either at a state or national level."

Jacob Shephard, MD

Missouri Resident Delegate, Jacob Shephard, MD, University of Missouri-Kansas City, shared his perspective on resolutions during the conference.

“During the first Congress of Delegates session, we learned about the elected resident positions and the upcoming resolutions. From the Missouri chapter Kate Rampon, MD, Mercy FMR, ran for the AAFP Foundation Board of Trustees and Kaci Larsen, MD, UMC FMR, ran for the AAFP COD resident delegate position. Going through the election process encouraged me to get

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

more involved in advocating for more resident and student involvement in running for elected positions. These positions help shape national healthcare policy and this gives Missouri a strong voice nationally.

I also had the opportunity to vote on resolutions. This was a great experience, because the Congress of Residents business sessions were formal and gave me a taste of what it would be like to work in a congressional setting either at a state or national level. We voted on resolutions regarding resident physician burnout and increasing access to the uninsured patient populations. One of the resolutions that was adopted was to work with the AMA in harmreduction strategies to prevent opioid overdoserelated events. With the experiences that I gained from this Congress, I hope to continue to advocate for my patients and be willing to step up and represent my patients and fellow resident physicians on a local and national stage.”

Kristin Thai, family medicine student at Kansas City University of Medicine and Biosciences, voted on these important measures which were presented to the AAFP’s Congress of Delegates conference in September.

Alicia Brooks, MAFP Resident Director, also attended and had this to share about her experience: “There is a national buzz about primary care and family medicine and nowhere was that more evident than at the AAFP National Conference of Family Medicine Residents and Students. It was invigorating to see so many hopeful medical students and dedicated residents gathered in one place. The vision for expanding and improving family medicine as a field is shared by many who attended. Reconnecting with old friends and making new connections while attending relevant lectures in the setting of a bustling but accessible Kansas City downtown was informative and fun. Missouri was well represented on our "street" in the exhibit hall, and medical students who are applying this year had the opportunity to mingle with all of our state's strong and diverse programs. There were events tailored to medical students still on the fence deciding if family medicine was the best fit for them, sessions for applicants such as interview tips and how to look for a good residency, as well as topical lectures covering things such as reading EKGs and performing obstetrics in family medicine. There

were recruiters looking to hire residents from all over the country, and free CV review through the AAFP CareerLink. Creative programming and interactive workshops rounded out the excellent conference. Overall, it was a wonderful three days and I highly recommend it!�

to students across the country and helped me to broaden my own world view. Lastly, I had the honor of being elected as the Student Member to the AAFP Board of Directors on Saturday morning of the conference. I also transitioned from being the Alternate Student Director to the Student Director on the MAFP Board of Directors on Friday evening. National Conference was an amazing experience and I look forward to attending again next year.

" " There is a national buzz about primary care and family medicine and nowhere was that more evident than at the AAFP National Conference."

Alicia Brooks, MAFP Resident Director

John Heafner, MAFP Student Director, and newly elected student representative to the AAFP Board, attended and had this to say, “As a 4th year medical student, there are many attractive aspects of the National Conference for Family Medicine Residents and Students.

Most notably, 4th year students from across the country attend the conference for the coveted residency fair to meet future colleagues and find the perfect program. While this was one component of my trip, I loved exploring the many other opportunities offered at National Conference. First, I had the opportunity to expand my clinical skills through participating in a handson ultrasound workshop. Along with deepening my clinical knowledge, I had the opportunity to broaden my horizons by learning about different practice models as well as hearing about advocacy in Family Medicine.

These activities helped me to grow as an individual, but I also had the opportunity to help improve and shape the future of family medicine through serving as a Reference Committee Chair.

In this role, I heard testimony on and created recommendations for the student congress resolutions that were written by fellow students and residents. These resolutions, if passed by the student congress, go to the Board of Directors so that the necessary actions can be taken. This experience highlighted issues that are important

Most notably 4th year students from across the country attend the conference for the coveted residency fair to meet future colleagues and find the perfect program." John Heafner MAFP Student Director

Participants in the 2017 National Congress of Family Medicine Residents debated nearly 30 resolutions on a variety of issues. Residents voted on topics related to physician well-being and burnout, personal finance education, patient advocacy, healthcare as a human right, and more.

Kaci Larsen, MD, of the University of MissouriColumbia Family Medicine Residency, described participation at the resident congress as learning opportunities. "Providing some feedback to the future leaders of family medicine would be beneficial," said Larsen. Specifically, residents and students could learn how to write clear and succinct resolutions now before they become "the real leaders of the Academy."

Advocating for Patients - Residents understand that sometimes they need to fight for their patients' most basic needs. Resolutions on food insecurity were submitted with testimony from a variety of attendees. The substitute resolution called on the AAFP to support efforts to screen patients for food insecurity and connect patients to federal nutrition programs, create a policy that

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supports a strong national nutrition safety net by defending federal nutrition programs from structural changes and budget cuts, and educate members about food insecurity.

In another resolution, residents asked the AAFP to collaborate with other organizations to develop resources to help family physicians become community advocates and collaborators for public health. The residents also tackled the topic of healthcare as a human right in light of the current status of the US healthcare policy. Delegates adopted a substitute measure asking the AAFP to recognize healthcare as a basic human right, rather than a privilege, for every person.

Keeping Patients Safe - Family medicine residents introduced several resolutions aimed at keeping their patients’ safe by addressing harm-

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reduction strategies to prevent opioid overdoserelated events, and mental health illnesses.

Residents also took up federal funding cuts to reproductive health programs.

• opposing federal funding cuts to reproductive health programs, • supporting legislation aimed at reducing adverse childhood experiences, • advocating against all-terrain vehicle use in children ages 12 and younger, • supporting the safety of personal care products, • creating an AAFP minority pipeline program, • connecting international students with AAFP chapters and • encouraging holistic selection of family medicine residency applicants.

Statewide WIC Program Builds Awareness of Developmental Milestones For the past seven years, the University of Missouri has worked with the state’s Women, Infants, and Children (WIC) nutrition program to promote earlier identification of developmental delays among children from low-income families. Starting with a pilot program in eastern Missouri and supported by research results, the WIC Developmental Milestones Program is now expanding through WIC agencies across the state. The program is funded by an innovative partnership between the Centers for Disease Control and Prevention (CDC) and the Missouri Department of Health and Senior Services.

Early identification and intervention are key to an improved quality of life for children with developmental delays, which affect 13 to 14% of all children. Children from low-income groups, such as those served by WIC, may lack access to screening services and miss the opportunity to benefit from early intervention.

“The WIC Developmental Milestones Program helps address these disparities and facilitate healthy development for all children as it builds relationships and resources throughout the state,” explains Janet Farmer, PhD, program director and principal investigator for MU.

The program is based on key messages of the CDC’s “Learn the Signs. Act Early.” public health campaign for parents: learn the signs of healthy child development; act early if there’s a concern; and talk to your child’s doctor.

WIC staff members use a set of checklists and family-friendly wall and floor graphics to increase parents’ awareness of typical child development. If a checklist suggests that a child is not reaching his or her age-specific developmental milestones, WIC staff refer that child to the doctor for screening and further assessment, just as they refer for other health concerns.

More information is available on the Missouri WIC website at http://health.mo.gov/living/families/ wic/wiclwp/wicdevelopmentalmilestonesprogram.

PART-TIME 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 part-time faculty position (Adjunct Assistant Professor) in the department of Family and Community Medicine.

A board-certified family physician with strong clinical skills and commitment to training future family physicians is sought to join our academic family practice. This position includes practice at an innovative Patient-Centered Medical Home at Saint Louis University and outpatient care for underserved patients at the John C. Murphy Health Center, with clinical teaching for medical students.

Application must be made online at http://jobs.slu.edu. Application must include a cover letter and curriculum vitae. In addition to applying online, applicants may send their curriculum vitae with an introductory letter describing their past experience to Christine Jacobs, M.D., Professor and Interim Chair, Department of Family and Community Medicine, 1402 S. Grand Blvd., St. Louis, MO 63104, or via e-mail to christine.jacobs@health.slu.edu.

Calls with questions are welcome in the department, 314-977-8480.

Review of applications begins immediately and continues until the position is filled. Saint Louis University is an affirmative action, equal opportunity employer, and encourages nominations of and applications from women and minorities.

MO-AFP.ORG 25

HDAs HelpDesk Answers

Interested in more HelpDesk Answers?

Get the answers to your clinical questions with a complementary 3 month electronic subscription to

Evidence-Based Practice!

To sign up for your free 3 month subscription, visit www.fpin.org/comp-ebp.

Ashley Davidson Turner, MD Carin Reust, MD, MSPH Laura Morris, MD, MSPH University of Missouri Columbia

26

How Effective is Continuous Glucose Monitoring in Patients with Type 1 Diabetes?

EVIDENCE-BASED ANSWER

In adults, continuous glucose monitoring used with pump-delivered insulin (PDI) or as part of an integrated, continuous monitor-in-pump delivered insulin (IPDI) system reduces glycated hemoglobin (HbA1C) 0.29 to 1.1 points more than self-monitoring of blood glucose with multiple daily injections of insulin (MDI). In young adults, continuous monitoring is no different from self- monitoring for lowering HbA1C. In children, continuous monitoring with PDI or IPDI lowers HbA1C by 0.24 points more than self-monitoring with MDI at 3 months (SOR: C, metaanalysis of RCTs with disease-oriented evidence). Use of continuous monitoring to lower HbA1C is supported in adults and may be helpful in children (SOR: C, expert opinion).

EVIDENCE SUMMARY

A

2012 systematic review of 22 RCTs (N=2,883 children and adults) examined whether continuous monitoring compared with self-monitoring at least once a day improved HbA1C levels over 3 to 18 months in patients with type 1 diabetes.¹ Insulin was administered by MDI, PDI, or IPDI. A subset of trials in children and adults, 1 to 70 years old, compared continuous monitoring with PDI or IPDI to self- monitoring with MDI. After 6 months, continuous monitoring and PDI led to slightly greater decrease in HbA1C than self- monitoring and MDI (6 trials, n=963; mean difference [MD] –0.52; 95% CI, –0.72 to –0.32). Continuous monitoring with IPDI compared to self-monitoring and MDI also led to slightly lower HbA1C after 6 months (2 trials, n=562; MD –0.68; 95% CI, –0.82 to –0.54). These changes in HbA1C persisted at 12 months with continuous monitoring and IPDI versus self-monitoring and MDI (1 trial, n=485; MD –0.60; 95% CI, –0.75 to –0.45).¹ Three RCTs in this systematic review examined combinations of continuous monitoring with IPDI or PDI compared to self-monitoring and MDI in adult men and nonpregnant women older than 24 years old for 3 to 12 months. In 1 RCT (n=77) continuous monitoring and PDI compared to self-monitoring and MDI showed a greater reduction in HbA1C at 3 months (MD –1.1; 95% CI, –1.5 to –0.75) and 6 months (MD –1.1; 95% CI, –1.5 to –0.74). Another RCT (n=98) comparing continuous monitoring with IPDI or PDI to selfmonitoring and MDI also showed greater reduction in HbA1C at 3 months (MD –0.29; 95% CI, –0.48 to –0.1) and 6 months (MD –0.52; 95% CI, –0.72 to –0.32). In a 12-month RCT (n=166), continuous monitoring with IPDI lowered HbA1C more than selfmonitoring and MDI (MD –0.60; 95% CI, –0.76 to –0.44). In young adults 15 to 23 years old, both RCTs

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

in this systematic review that examined continuous monitoring with IPDI or PDI with self-monitoring and PDI found no difference in HbA1C at 3 or 6 months.¹ Four RCTs in the systematic review examined continuous monitoring and self-monitoring in various combinations with IPDI, PDI, and MDI in children younger than 15 years. In 1 RCT (n=114), continuous monitoring with IPDI or PDI showed a slightly greater decrease in HbA1C than self-monitoring and MDI at 3 months (MD –0.24; 95% CI, –0.47 to –0.01), but no difference at 6 months. Other comparisons of continuous monitoring with IPDI to self-monitoring and PDI or MDI showed no difference at 6 or 12 months.¹ The validity of this review was limited by significant heterogeneity in age, baseline HbA1C, method of insulin delivery, and type of continuous monitor used in each study. All studies were sponsored by the monitor manufacturer, with 6 stating no conflict of interest.¹ The 2015 American Diabetes Association standards of medical care in diabetes supports the use of continuous monitoring with intensive insulin regimens to lower HbA1C in adults aged ≥25 years (Level of evidence: A, based on RCTs).² Continuous monitoring in children, teens, and younger adults may be helpful (Level of evidence: B, based on cohort studies). Proper use of the monitor, patient education, and ongoing support may improve success with continuous monitoring for all age groups.² 1. Langendam M, Luijf YM, Hooft L, DeVries JH, Muddle AH, Scholten RJ. Continuous glucose monitoring systems for type 1 diabetes mellitus. Cochrane Database Syst Rev. 2012; (1):CD008101. [STEP 1] 2. American Diabetes Association. Standards of medical care in diabetes – 2015. Diabetes Care. 2015; 38(suppl 1):S33– S40. [STEP 5]

MO-AFP HAS SIGNED ON! PCPCC 601 Thirteenth Street, NW, Suite 430 North Washington, DC 20005 P: (202) 417-2081 F: (202) 417-2082

What is PCPCC?

Realizing the future of primary care occurs faster when all stakeholders can speak with one voice. We’ve signed on to support the new Shared Principles--developed by stakeholders representing all aspects of healthcare -- and designed to move the United States toward a vibrant future of personcentered, team-based, community aligned primary care. The new Shared Principles of Primary Care provides a common vision for the future of primary care and we’re proud to announce our support.

pcpcc.org

Founded in 2006, the Patient-Centered Primary Care Collaborative (PCPCC) is a not-for-profit multi-stakeholder membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home. Representing a broad group of public and private organizations, the PCPCC’s mission is to unify and engage diverse stakeholders in promoting policies and sharing best practices that support growth of high-performing primary care and achieve the “Quadruple Aim”: better care, better health, lower costs, and greater joy for clinicians and staff in delivery of care. The PCPCC is and will position itself as an advocacy organization—a coalition that serves as a “driver of change,” educating and advocating for ideas, concepts, policies, and programs that advance the goals of high-performing primary care as the foundation of our healthcare system.

MO-AFP.ORG 27

Pabst Elected to Serve on AAFP's CEAC Kathy Pabst, MBA, CAE, Executive Director of the MAFP, was recently elected to serve on the AAFP Chapter Pabst Executive Advisory Committee (CEAC). She fills an at-large vacancy for a three-year term beginning in February, 2018.

The CEAC is made up of six chapter executives elected by the chapter executives with two new members joining and two members rotating off each year. As a member of this committee, Kathy will provide the AAFP Executive Vice President with feedback from chapters about AAFP programs, initiatives, services and issues. She will also ensure all viewpoints are represented and provide status reports to the chapter executives throughout her term.

Larsen Appointed Delegate to AMA Kaci Larsen, MD, has been appointed to represent the American Academy of Family Physicians (AAFP) as a Larsen delegate to the American Medical Association Resident Fellow Section. Larsen's term begins in November of 2017 and lasts through the fall of 2018.

28

MEMBERS

IN NEWS the

NEWS TO SHARE?

The Missouri Family Physician magazine welcomes your input.

Please submit newsworthy items for review to: office@mo-afp.org

Belihu Receives Diploma in International Health Mihiret Belihu, MD, PGY3, Mercy FMR, received her diploma in International Health from IN-MED in Kansas City, MO. Belihu completed a four-week global health rotation in Ethiopia as her practicum for her diploma. Below is a excerpt from Dr. Belihu's experience:

"

"I had the privilege of going to Soddo, Ethiopia on a one-month rotation in July as a part of my International medicine and public health Diploma program through INMED. Soddo Christian Hospital is a missionary-run hospital with local staff and physicians as well.

My experience was a get away from all the luxury of fancy diagnostic modalities, the ease of referrals, care at your fingertips as well as the nuances of EMR. I came face to face not only with the science but also the healing art of medicine. I was living in a guest house in the hospital compound which was bonus as

I got to experience not only the work environment, but also, break bread and attend chapel and prayer meetings which are the integral part of the ministry. I have always known I wanted to do Global/Medicine but I did not think I would be able to do it during my residency; so thank you everyone who made it possible! And yes I would definitely go back to Soddo!"

White Joins Mercy FM Welcome new faculty, Stefanie White, MD, to Mercy Family Medicine.

Dr. White graduated White from Saint Louis University School of Medicine and completed residency at Via Christi Family Medicine in Wichita, KS. She has particular interest in maternity care and women’s health.

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

'Welcome to Family Medicine' Picnic

Christine Jacobs, MD, Program Director, speaks to a group of students during the picnic.

Saint Louis Academy of Family Physicians held their annual 'Welcome to Family Medicine' picnic on Sunday, Aug. 20 at the home of Dr. Walt Sumner. The picnic was attended by 45 Saint Louis University students, seven Washington University students, and seven physicians and their families.

Externship Reflection - Rollet

Amber Rollet University of Missouri - Kansas City This summer, I was fortunate to be awarded an externship from the Family Health Foundation of Missouri. I spent four weeks at the University of Missouri – Columbia. My experience proved very valuable to me as I was able to learn more about medicine and their program, as well as many of the community resources that Columbia and Missouri has to offer patients. Another beneficial element to the summer externship was receiving first hand experience of what this residency program has to offer. From inpatient medicine to weekly continuity clinic, didactics, and research meetings that were held, I recognized just how truly unique and important each patient is to the University of Missouri-Columbia.

"

My summer of study in the program solidified the multitude of reasons why I love family medicine."

Heafner, New AAFP Student Board Member

During the 2017 Congress of Delegates (held in mid-September), John Heafner, MPH, was elected Student Board Member by the AAFP Congress of Delegates. Heafner is currently a student member of the AAFP Commission on Health of the Public and Science, a member of the Family Medicine for America’s Health Student and Resident Work Group, and the Missouri Academy of Heafner Family Physicians’ Student Director.

In Memoriam Mercy Family Medicine was saddened by the loss of faculty emeritus Thomas Johnson, MD, who was laid to rest in January 2017. Dr. Johnson cherished his forty-year career in family medicine and modeled servant-leadership during his tenure as faculty, program director and department Johnson chair at Mercy Family Medicine. As his beloved family expressed, “Always an example that there is nothing more important in life than love, he will be remembered and celebrated for gracefully sharing his unwavering desire for life, health and happiness.” We are grateful for Dr. Johnson’s integral and indelible impact on the patients, staff, physician and alumni of Mercy Family Medicine.

Externship Reflection - Abraham

Seenu Abraham University of Missouri - Kansas City This summer, I was selected to participate in a four-week family medicine externship experience with Research Family Medicine Residency. I had the pleasure of working alongside residents and faculty at Research hospital, Goppert-Trinity Family Medicine clinic as well as an obstetrics outreach clinic in Harrisonville, MO. I started the externship with a week of inpatient service.

Paired with a second year FM resident, I followed one to two of his patients daily and presented them to our attending. From the start, I felt welcomed and was treated as a fellow team member.

With an interest in hospitalist medicine, it was refreshing to see the sheer variety of pathology that family medicine physicians are trained to manage and the skills obtained in the process.

During the second week, I worked closely with the OB team to efficiently triage OB visits, help with deliveries, and perform newborn exams. In addition, I saw continuity patients for their prenatal care in the OB outreach clinic once a week. Fortunately, I was able to follow many of the same patients as they moved further along in their pregnancy. It was especially rewarding to provide a patient with prenatal counseling in the clinic and ultimately be present for the delivery at the hospital by the end of month.

I spent the third week on night shift with the inpatient residents. This experience was particularly helpful. I enjoyed building on my interview and exam skills as we admitted multiple patients throughout the week. I participated in my first code, in which I performed chest compressions. In the off time, the residents provided valuable teaching points and gave advice for me moving forward in my career.

Finally, the last week was spent at Goppert-Trinity Family Care where I saw a variety of clinic visits including urgent care, chronic management, well child visits, and many procedures. I was able to observe colposcopies in the specialty clinic, perform some joint injections and skin procedures. Both in the hospital and the clinic settings, I was able to appreciate the focus on teaching and overall wellness among residents. As a student who will be applying to residency in the near future, it was helpful to witness resident-faculty interactions and see how their program is set up.

This experience challenged me to determine aspects of training that are important to me as I further along in my medical career."

I would like to thank the Family Health Foundation of Missouri and AAFP for this amazing opportunity. It surely opened my eyes to the broad range of pathology and opportunity found with a career in family medicine. I am thankful for the chance to build my knowledge and skills as a future primary care physician.

MO-AFP.ORG 29

MISSOURI ACADEMY OF

FAMILY PHYSICIANS STRONG MEDICINE FOR MISSOURI

Thursday, November 9, 2017

Saturday, November 11, 2017

Friday, November 10, 2017

suppofrtm fh alth ly He Famui ndationri Fo issou of M

Sunday, November 12, 2017

REGISTER BY OCT. 10 AND SAVE $50!

Book your stay today! To receive the MAFP group rate, reference 'Group # 61C2RI' • Valley View Double Queen: $149 • Private Two Bedroom Cabin: $482 612 Devil's Pool Road Ridgedale, Missouri 65739

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25th Annual Fall Conference Registration Form Missouri Academy of Family Physicians 722 West High Street, Jefferson City, MO 65101 Email: office@mo-afp.org Phone: 573.635.0830 Fax: 573.635.0148 to register Visit mo-afp.org NovemberWant 10-11, 2017 |online?

Big Cedar Lodge

ANNUAL FALL CONFERENCE REGISTRATION FORM

AAFP ID: Name:

 MD

 DO

Address:

City/State/Zip:

Telephone:

Email:

 FAAFP

One Day Only

 Other:

Full

Amount

MAFP Member* New Physician, Life Member, or Allied Health Professional AAFP Member (Out of State)

$200

 Friday

 Saturday

$375

$

$175

 Friday

 Saturday

$300

$

$210

 Friday

 Saturday

$400

$

Non-Member

$250

 Friday

 Saturday

$475

$

$200

$

$25

$

Total A

$

KSA Working Group

Sunday – (8:00 a.m. – 2:30 p.m.)

Printed Syllabus (Free for Life members)

$25

*AAFP Membership includes state chapter membership.

Event Conference Attendee (Check all that apply.)

Friday Breakfast

Friday Lunch



Guests

_____ x $20 Each

RSVP

Saturday Breakfast

Saturday Lunch







_____ x $25 Each

____ x $20 Each

_____ x $25 Each

Total B + Total A Don’t forget Early Bird Discount (received on or before 10/10/17) | -$50 Does not apply to one-day registration or KSA Working Group Wine, Beef, and Cheese Pairing $50 (Proceeds benefit FHFM) (Optional) Family Health Foundation of Missouri 50/50 Raffle (Optional) Tax ID 43-1480324 | $10 per ticket or 6 for $50 Total Amount Due

Amount $

Included

$ $ $ $ $ $

Special Dietary Needs or Physical Accommodations: ____________________________________________________________________________ Registration Information: • CME sessions, meals, breaks, and electronic syllabus are included in the registration fee. All functions in the Exhibit Hall are for registrants only.

• KSA Working Group includes continental breakfast, lunch and refreshments.

• By registering for this conference, I authorize MAFP to use photographs of me with or without my name for any lawful purpose, including print or online marketing.

• Registration cancellations must be in writing (to office@mo-afp.org) and received no later than October 4, 2017. A $50 administrative fee will be deducted from each refund processed. No refunds will be issued after this date.

Questions? Call (573) 635-0830, Fax (573) 635-0148, or email at office@mo-afp.org Payment Information:

Check (Made payable to MAFP-enclosed)

MasterCard

VISA

Discover

 AMEX

Name on Credit Card:__________________________________________ Expiration Date:___________ Security Code:___ ___ ___ Card #: ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___

Billing Zip Code:____ ____ ____ ____ ____

Signature:__________________________________________________________

Missouri Academy of Family Physicians 722 West High Street Jefferson City, Missouri 65101

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Missouri family physicians Be the voice of

Participate in Advocacy Day at the state Capitol. Bring a colleague, medical student or resident and join fellow Missouri Academy members to promote the importance of family medicine and primary care to our state legislators. This is your opportunity to educate your State Representative and Senator on issues affecting you, your profession, and your patients.

LODGING: Capitol Plaza Hotel has provided a group rate of $99 single/double for Monday evening, February 19.

Call the hotel direct at (573) 635-1234 to make your reservation and be sure to mention the “Missouri Academy of Family Physicians” to receive the discounted rate. A limited number of complimentary sleeping rooms are available on a first come, first served basis for those attending the Monday evening legislative briefing.

Contact the MAFP Office for availability and to reserve one of these rooms.

FEBRUARY 19-20, 2018 • CAPITOL PLAZA HOTEL • JEFFERSON CITY, MISSOURI Monday, February 19, 2018 – 6:30 – 8:30 p.m.

Detailed legislative briefing at Capitol Plaza Hotel Tuesday, February 20, 2018 – 7:30 a.m. – 1:30 p.m.

Legislative briefing and breakfast at Capitol Plaza Hotel Visit your legislators’ offices (appointments will be scheduled for you by MAFP staff) Buffet Luncheon at Capitol Plaza Hotel – 11:30 a.m. – 1:30 p.m.

Board of Directors Meeting (working lunch) 1:30 – 5:00 p.m.

For more information, contact the MAFP office at (573) 635-0830 or office@mo-afp.org

FACULTY CLINICIAN EDUCATOR 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 physician with strong clinical skills and commitment to training future family physicians is sought for an 80% clinical and 20% academic faculty position in a vibrant and collaborative department. Practice will consist of a clinical ambulatory practice with faculty colleagues in an innovative Patient Centered Medical Home on the medical campus at Saint Louis University with an option for inpatient medicine. Join a large academic faculty for clinical teaching of medical students and residents in clerkships, electives, seminars, and mentoring of medical students for family medicine careers. Support and mentorship is provided for scholarship and research.

Application must be made online at http://jobs.slu.edu and include cover letter and curriculum vitae. Applicants may contact the department directly by calling 314-977-8480, by sending CV and cover letter to Christine Jacobs, M.D., Professor and Interim Chair, Family and Community Medicine, 1402 S. Grand Blvd., St. Louis, MO 63104, or via e-mail to christine.jacobs@health.slu.edu.

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.

MO-AFP.ORG 33

2017 Congress of Delegates Focuses on Patients First

W CONGRESS OF DELEGATES

ork for the annual AAFP Congress of Delegates (COD) usually begins in June when the various chapters have submitted resolutions to the AAFP for consideration at the Congress of Delegates. The AAFP is now comprised of 55 chapters representing 129,000 members. Each chapter sends two delegates, two alternate delegates, their president, and chapter executive to attend this policy making meeting.

Your MAFP team, consisting of Delegates Todd Shaffer, MD, and Keith Ratcliff, MD, Alternate Delegates Kate Lichtenberg, DO, and Peter Koopman, MD, Mark Schabbing, MD, MAFP President, and Executive Director, Kathy Pabst, began the work of the Congress early in the summer. Resolutions submitted from any constituent chapter can be considered by the Congress, and a wide range of issues is always presented for debate.

"

We may not have the same value beliefs, politics, or solutions, but all have the same common interest, serving and advocating for the health of our patients."

Mark Schabbing, MD MAFP President

This year, 57 Resolutions were filed ahead of time, including a resolution written by the MAFP team in celebration of our 70th anniversary. Two late resolutions concerning the recent hurricanes devastating Texas and Florida were added from the floor. Your MAFP COD team began reading the resolutions and considering the background information about three months ago, and after a survey of the MAFP Board, there were 21 resolutions that were judged to be either “very important” or “important” to our MAFP members.

The submitted resolutions are then divided by topic among one of five reference committees:

34

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

Education, Advocacy, Practice Enhancement, Health of the Public and Science, or Organization and Finance.

As with past sessions of COD, chapter leaders were drawn to a town hall meeting to kick off the three-day conference. AAFP leadership served on this panel to field questions from the attendees.

One of the top three issues raised by family physicians and identified in the AAFP's annual member satisfaction survey was simplifying the maintenance of board certification process.

Prior authorizations and other problematic administrative and regulatory issues also sparked discussion by participants. Physicians also voiced their support to continue efforts to advocate for healthcare for all. Other hot topics included scope of practice, health equity and social determinants of health, healthcare reform and single-payer healthcare systems.

"We're keeping patients in focus," said Mike Munger, MD, AAFP President.

AAFP leaders consistently discussed universal healthcare for all and physician wellness. The AAFP has had a policy supporting universal healthcare since 1989 and we were among the signatories of the United Nations Declaration of Human Rights in 1948. Doug Henley, MD, AAFP CEO, and Mike Munger, MD, AAFP’s Newly Elected President, acknowledged the “administrative burden” and will be working to reduce those challenges in the upcoming year.

After hearing testimony on the resolutions, each reference committee produces a consent calendar advising the Congress on its recommendation for each item.

Recommendations from the reference committee can be to adopt, not adopt, refer to the AAFP Board, or a substitute resolution can be offered.

Delegates may “extract” an item from the reference committee report to be debated on the floor of the entire Congress if they so choose. For example, the MAFP submitted Resolution 204 for which the Reference Committee on Organization and Finance suggested a “Substitute Resolution” which read: “RESOLVED, that all chapters of the AAFP be recognized on their platinum anniversary”. Because this substitute captured the intent of our original resolution, there was no reason to “extract it” for floor debate and we chose to let it be passed by acclimation on the

CONGRESS OF DELEGATES

consent calendar. Many other resolutions were vigorously debated on the Congress floor before a final vote. You can read the final disposition of all resolutions on the AAFP website at http:// www.aafp.org/about/governance/congressdelegates/2017.mem.html.

Other resolutions brought before this governing body addressed investigating how to provide the patient's voice to the AAFP Board of Directors and how to support employed physicians in their efforts to participate in AAFP leadership activities.

A major effort of the MAFP delegation this year was the campaign to elect Todd Shaffer, MD, to the AAFP Board of Directors. Kathy, Sarah, and Becki worked tirelessly on the campaign for months over the summer, as did Todd in preparation for the speech and Q&A sessions.

There was a very strong field of candidates, and unfortunately, we were not successful.

Depending on Dr. Shaffer’s wishes, we are ready to begin the process again next year with your support.

The Congress elected Sterling Ransome, MD, of Virginia, Wendel Stracener, MD, of Indiana, and Erica Swegler, MD, of Texas as your new Board members. John Cullen, MD, of Alaska, was elected as our new President Elect, and Russell Kohl, MD, of Oklahoma, was elected as Vice Speaker. Mike Munger, MD, of Kansas (previously from Missouri) was installed as our new President. Your entire delegation would like to thank you for the opportunity to represent Missouri on this national stage, and we look forward to the future.

John Heafner, MPH, student, Saint Louis University, was elected as the student representative to the AAFP board. His nomination was ratified from the National Conference of Family Medicine Residents and Students held in Kansas City (July).

MAFP President, Mark Schabbing, MD, attending this year’s Congress and he noted that it was an opportunity to observe how ideas are brought forth and meshed into policy for our organization. Schabbing stated that he, “found it interesting to see how so many family physicians coming from so many different back grounds and practicing in different settings have very similar problems. We may not have the same value beliefs, politics, or solutions, but all have the same common interest, serving and advocating for the health of our patients. When disagreements occurred, delegates listened with respect for their colleagues. I left the meeting knowing that the AAFP has strong leadership and is standing strong to support our needs and the needs of our patients as a whole.”

SHOW ME

WHAT MATTERS

SHOW ME

WHAT MATTERS

SHOW ME

WHAT MATTERS

SHOW ME

WHAT MATTERS

SHOW ME

WHAT MATTERS MO-AFP.ORG 35

2017-2018 2017-2018 COX FAMILY MEDICINE COX FAMILY MEDICINE RESIDENCY Faculty

Kyle W. Griffin, MD Program Director

Gabrielle I. Curtis, MD Associate Program Director – Clinical Medicine

Kristen F. Glover, MD Family Medicine

Michael C. Kabonic, DO Family Medicine

Angela Conklin, DO, MBA OB Fellow

Shelby R. Hahn, MD Associate Program Director – Residency Education

Jessica D. Standeford, MD Family Medicine

Jacque J. Gordon, PsyD Psychologist

Cameron A. Crymes, MD Family Medicine

Audrey M. Williams, DO Family Medicine OB Fellowship Director

Ashley M. VanHorn, NP Nurse Practitioner

Kristin A. Crymes, DO Family Medicine

Brian D. Williams, MD Family Medicine

Residency Administrator

Katie L. DavenportKabonic, DO Family Medicine

Michael E. Lynch, MD OB/GYN

Rhonda L. Robinson Clinic Administrator

Third-Year Resident Physicians Aaron R. Buzard, MD, MPH

Blake A. Fulks, MD Chief Resident

Meghan E. Guthrie, MD Chief Resident

Shannon N. Marsden, MD

Caitlin S. Schmitt, DO

Kenneth F. Starnes, III, MD

Lisa S. Trask, DO

Sarah A. Williams, MD

SecondYear Resident Physicians

Jennifer C. Bulcock, MD

Matthew D. Dalke, MD, MA

Whitney J. Davis, DO, MS

Alyssa A. Easter, MD

Jenny M. Eichhorn, MD

J. Cliff Ganus, MD, MPH

J. Evan Johnson, MD

John P. Long, III, MD

Lukas Mathews, MD

Lauren J. Branham, DO, MBA

Evan A. Branscum, MD

James Brecheisen, MD

Trevor J. Conner, DO

Kyle A. Gillett, MD

Brian D. Kennedy, MD

Kelsey L. Keoppel, DO

Kayla B. Matzek, MD

First-Year Resident Physicians

Joshua W. Gaede, MD

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MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

2017-2018 Mercy Family Medicine MERCY FAMILY MEDICINE 2017-2018 First-Year Resident Physicians

Robyn Brownell, MD Dallas Chase, MD Rush Medical College Ross University School of Medicine

Kyle Johnson, DO AT Still University of Health Sciences Kirksville

Whitney Knapp, DO AT Still University of Health Sciences Kirksville

Kim McClure, MD Saint Louis University School of Medicine

Ryan Menchaca, MD University of Texas School of Medicine at San Antonio

Second-Year Resident Physicians

Ann Lottes, MD University of Missouri Columbia School of Medicine

Eric Martin, DO Des Moines University College of Osteopathic Medicine

Kate Rampon, MD University of Tennessee Health Science Center College of Medicine

James Starrett, DO Kansas City University of Medicine and Biosciences

Brittanie Weinhaus, DO AT Still University of Health Sciences Kirksville

Rebecca Winchester, DO Kansas City University of Medicine and Biosciences

Third-Year Resident Physicians

Cherry Cockrell, MD University of Oklahoma College of Medicine

Sally Kurz, MD University of Texas Southwestern Medical Center

Jeremy Oliver, DO Kansas City University of Medicine and Biosciences

Daniel O’Loughlin, DO AT Still University of Health Sciences Kirksville

Brett Warden, DO Kansas City University of Medicine and Biosciences

Mark Zacharjasz, MD Saint Louis University School of Medicine

MO-AFP.ORG 37

2017-2020

2017-2018 2017-2018 RESEARCH FAMILY MEDICINE RESIDENCY PROGRAM RESEARCH FAMILY MEDICINE RESIDENCY PROGRAM RESEARCH FAMILY MEDICINE RESIDENCY PROGRAM KANSAS CITY, CITY, MISSOURI KANSAS MISSOURI KANSAS CITY, MISSOURI 2017-2018 R3 CHIEF RESIDENTS 2017-2018 R3 CHIEF RESIDENTS

Dianne Elledge, DO

Ed Christiansen, MD

Anna Robert Dianne Kreikemeier, DO Anna Hanson, MD Elledge, DO Hanson, MD

Joseph Meier, MD

Christopher Georgina Joanita Kendall Tommel Christopher Idicula, MD Georgina Johnson, DOJoanita Samani, MDKendall Fotopoulos, DOEd Green, MD Christiansen, MD Fotopoulos, DO Green, MD Idicula, MD Johnson, DO

Will Varsha Patton, DOJoseph Pawate, MD Will Meier, MD Patton, DO

Sabrina Sahadevan, MD

38

Daniel Emily Haire, DO Rachel Hansen, DODaniel Allen, MD Haire, DO

Hazen Maureen Max Maureen Short, MDVarsha Weber, MD Hazen Zollicker, MD Pawate, MD Short, MD Weber, MD

Tommel Samani, MD

Brittney Frisby, MD

Max Zollicker, MD

CLASS 2020

Christine Rachel Sean Christine Rutschke, DORachel Khong, MDEmily McDonald, MD Hansen, DO Khong, MD McDonald, MD

Joseph Ben Kayt Rhiannon Chelsea Sabrina Ben Sayegh, MD Saylor, DO Joseph Schlepphorst, MD Talbot, DO Kayt Willis, DORhiannon Sahadevan, MD Sayegh, MD Saylor, DO Schlepphorst, MD Talbot, DO

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

Christopher Chappell, DO

CLASS OF 2019

Gaurav Sourab Gewel Manveer Brittney Priscilla Chopra, MDGaurav de los Santos,Sourab Chaturvedi, MD, MD Flora, MD Gewel Frisby, MDManveer Chaturvedi, MD, Chopra, MD de los Santos, MD Flora, MD PhD Borden, MD PhD

CLASS 2020

Rachel Allen, MD

CLASS OF 2018

Faisal Nathan Christopher Ali, MD Robert Boehr, DO Faisal Chappell, DONathan Kreikemeier, DO Ali, MD Boehr, DO

CLASS OF 2019

Priscilla Borden, MD

CLASS OF 2018

Sean Rutschke, DO

Chelsea Willis, DO

2017-2018 SAINT LOUISLOUIS UNIVERSITY SAINT UNIVERSITY FAMILY MEDICINE FAMILY MEDICINE RESIDENTS – 2017-2018 PGY3:

Michelle Hall, MD CHIEF RESIDENT Saint Louis University School of Medicine

Jared Henrichs, MD CHIEF RESDIENT Southern Illinois University School of Medicine

Preethi Schmeidler, MD University of Kansas School of Medicine

Alicia Brooks, MD East Tennessee State Quillen School of Medicine

Michael Donovan, MD University of Illinois College of Medicine

Ritesh Gandhi, MD Chicago Medica; School

Brittany Goodrich-Braun, MD Saint Louis University School of Medicine

PGY2:

Joseph Moleski, DO Kansas City University of Medicine & Bioscience

Lauren Waible, DO Lake Erie College of Osteopathic Medicine

Deanna Chavez, MD Creighton University School of Medicine

PGY1:

Yibing Li, MD University of North Carolina Chapel Hill School of Medicine

Alison Matsunaga, MD Saint Louis University School of Medicine

Peter Ireland, MD Saint Louis University School of Medicine

Ashley Meyr, MD Saint Louis University School of Medicine

Randy Jackson, MD Rutgers, Robert Wood Johnson School of Medicine

Kelly Dye, MD Texas Tech University School of Medicine

Khranasa Mohebpour, MD University of Texas School of Medicine

Robert Hieger, MD Saint Louis University School of Medicine

Daniel Stevens, DO Des Moines University College of Osteopathic Medicine MO-AFP.ORG 39

2017-2018 DEPARTMENT OF FAMILY & COMMUNITY MEDICINE UNIVERSITY OF MISSOURI COLUMBIA UNIVERSITY OF MISSOURI | SCHOOL OF MEDICINE 2017-2018 HOUSE STAFF DEPARTMENT OF FAMILY & COMMUNITY MEDICINE Chief Residents

Sarah Kirchhoff, MD Fulton

Krystal Foster, MD Family Health Center

Andy Peterson, MD Fulton

Tim Ratliff, DO SP-Blue

Third-Year Residents

Nick Bratten, MD SP-Blue

Parker Kohlfeld, MD Fulton

Joshua Bacon, MD Fulton

Jonathan Hoskins, MD Fayette

Chase Beliles, MD Fulton

Shari Chang, MD SP -Blue

Patrick Granneman, DO Fayette

Becca Hogg, MD Family Health Center

Katie Martinez, MD SP-Green

Drew Satterfield, DO Fulton

Geoffrey Dankle, MD Fulton

Brady Fleshman, MD SP-Gold

John Jayroe, MD SP-Green

Kaitlin Saucier, MD Fayette

Calvin Tai, MD SP- Blue

Second-Year Residents

Ben Crary, DO Fulton

Kaci Larsen, MD Fayette

Stephanie Lersch, MD Family Health Center

James Tucker, DO Fayette

Lisa Camilleri, MD SP-Gold

Justin Chang, MD SP-Gold

Gabriel Eljdid, DO SP-Gold

Stephanie Espinoza, MD Family Health Center

Eric Kadlec, MD Fulton

Mary Murphy, MD SP-Green

Misty Todd, MD Fulton

Carl Tunink, MD Fulton

Alex Finck Fayette

40

First-Year Residents

Andrew Hinojosa, MD SP-Green

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

Integrated Residents

Colin McDonald Family Health Center

Zach Treat Fulton

Kristen Killen, MD Family Health Center

Aaron Wood, MD Family Health Center

Tyler Gouge, MD Fayette

Lisa Wadowski, MD SP-Blue

MO-AFP.ORG 41

Steven Taki, MD University of Washington SOM

Adam Legg, DO Kansas City University

Lauren Carpenter, MD University of Nebraska

Brandon Abbott, DO ATSU Kirksville

Andrew Wherley, MD University of Illinois

Caroline Martin, DO, MS Kansas City University

Ashley Hall, DO AT Still Kirksville

Cassandra From, DO Kansas City University

Hannah Anderson, MD University of Kansas

Noushin Ansari, MD UMKC

Joshua Williams, MD UMKC

Andrew Wherley, MD University of Illinois

Kevin Munger, DO, MS Des Moines University

Steven Taki, MD University of Washington SOM

Caroline Martin, DO, MS Kansas City University

Adam Legg, DO Kansas City University

Cassandra From, DO Kansas City University

Lauren Carpenter, MD University of Nebraska

Noushin Ansari, MD UMKC

Brandon Abbott, DO ATSU Kirksville

Joshua Williams, MD UMKC

Bhavishya Narotam, DO Kansas City University

Kevin Munger, DO, MS Des Moines University

Robbie Harriford, MD University of Kansas

Ashley Hall, DO AT Still Kirksville

Karina Belino, DO ATSU

Hannah Anderson, MD University of Kansas

Aaron Neisen, DO, MBA Kansas City University

Bhavishya Narotam, DO Kansas City University

Helen Hill, DO, MPH ATSU—SOMA

Robbie Harriford, MD University of Kansas

UFR des Sciences Médicales de l’université de Bordeaux

Jessica Braure, MD, PhD

Karina Belino, DO ATSU

Hong Nguyen, MD University of Kansas

Aaron Neisen, DO, MBA Kansas City University

Matt Hendrix, MD UMKC

Helen Hill, DO, MPH ATSU—SOMA

Joshua Booth, MD University of Arkansas

UFR des Sciences Médicales de l’université de Bordeaux

Jessica Braure, MD, PhD

Theresa Nguyen, DO, MS Kansas City University

Hong Nguyen, MD University of Kansas

Maaroof Islam, MD UMKC

Matt Hendrix, MD UMKC

Megan Buri, MD Creighton

Joshua Booth, MD University of Arkansas

Holly Perkins, MD Creighton

Theresa Nguyen, DO, MS Kansas City University

Christopher Koehn, DO, MBA Kansas City University

Maaroof Islam, MD UMKC

Josh Buschling, DO Rocky Vista

Megan Buri, MD Creighton

Jessica Richter, DO, MPH Lake Erie College

Holly Perkins, MD Creighton

Andrew Kwan, MD, MBA University of Kansas

Christopher Koehn, DO, MBA Kansas City University

Chadwick Byle, MD University of Missouri

Josh Buschling, DO Rocky Vista

2017-2020 UNIVERSITY OF MISSOURI - KANSAS CITY FAMILY MEDICINE TRUMAN MEDICAL CENTER - LAKEWOOD

Jacob Shepherd, MD SABA University

Jessica Richter, DO, MPH Lake Erie College

Benson Lan, MD St Louis University

Andrew Kwan, MD, MBA University of Kansas

Jennifer Cabral, MD Creighton

Chadwick Byle, MD University of Missouri

Hailey Avila, DO UMKC Sports Medicine Fellow Family Medicine

Gretchen Stokes, MD UMKC

Jacob Shepherd, MD SABA University

LiYin Lan, DO, MBA Kansas City University

Benson Lan, MD St Louis University

Chelsie Cain, DO ATSU

Jennifer Cabral, MD Creighton

Kevin Gray, MD UMKC Sports Medicine Fellow Family Medicine

Hailey Avila, DO UMKC Sports Medicine Fellow Family Medicine

Ryan Stokes, MD UMKC

Gretchen Stokes, MD UMKC

Nicole Lee, MD University of Virginia

LiYin Lan, DO, MBA Kansas City University

Ryan Carey, DO, MA, MPH Touro CA

Chelsie Cain, DO ATSU

7900 Lee's Summit Road Kansas City, MO 64139 Ph: 816-404-7751 Fax: 816-404-7756 Email: info@umkcfm.org

Sp

Uni

Ryan

7900 Lee's S Kansas City, Ph: 816-404Fax: 816-404Email: info@u

Iowa, MIssourI & Nebraska acadeMy of faMIly PhysIcIaNs

2018 alaskaN cMe cruIse aboard the celebrIty solstIce

July 13-20, 2018

shIP deParts froM seattle, washINgtoN

2018

THE ALASKAN CME CRUISE We are pleased to announce

that the Iowa, Missouri & Nebraska Chapters have joined together to offer you a breathtaking, unique, and memorable vacation cruise to Alaska! Join us as we depart from Seattle and explore various ports in Alaska and Canada aboard the beautiful Celebrity Solstice for a week full of relaxation, fun, and CME. Ship Departs from Seattle, Washington with stops at ports in: 1 KetchiKan 2 tracy arm FjorD 3 juneau 4 inSiDe paSSage/ SKagWay 5 Victoria, BritiSh columBia

each cabin oceanview category and above will have the choice of 1 complimentary perk for 1st and 2nd guest only: o $150 per person onboard credit o Prepaid gratuities o Classic beverage package (includes alcoholic beverages up to $9, and soda package) o Unlimited internet Please note: 3rd & 4th guests will automatically receive the classic soda package and 40 internet minutes

ADDITIoNAL INFoRMATIoN:

delivered by your colleagues. CME will be scheduled for the mornings we are at sea. Details and programming will be updated on the website as we finalize topics/speakers

• Gratuities are $94.50 per person for all categories except suites which are $98 per person.

• Travel Protection is available through Celebrity for $159 per person payable with final payment.

CRUISE REgISTRATIoN: (all fees are per person)

CRUISE DEpoSIT/ pAyMENT SCHEDULE:

CME: You will have the opportunity to participate in 12 to 15 credits of CME

There are limited cabins available in the categories below.

rates are cruiSe only 1st & 2nd guest. 3rd & 4th guest current rate at time of booking per celebrity tBD. airfare is not incluDeD.

o A1-Aqua Class $2711.30 o C2-Concierge Class $2561.30 o 1C- Deluxe Oceanview w/Verandah $2361.30 o 2A- Deluxe Oceanview w/Verandah $2341.30 o 2B- Deluxe Oceanview w/Verandah $2301.30 o S2- Sky Suite $3811.30 o 9- Inside Stateroom $1581.30

• Deposit is $500 per cabin and $1000 per suite due upon registration.

• Final Payment is due by April 13, 2018

CRUISE CANCELLATIoN/ATTRITIoN:

• From 89-57 days prior to sailing the cancellation penalty is $250.00 per person.

• From 56-29 days prior to sailing the cancellation penalty is 50% per person.

• From 28-15 days prior to sailing the cancellation penalty is 75% per person.

• From 14-0 days prior to sailing there is no refund.

To RESERVE A CABIN:

please visit our website at

www.iaafp.org/alaska

You must register for the CME portion of the cruise separately this can be done by going to www.iaafp.org/alaska under the education tab.

42

MISSOURI FAMILY PHYSICIAN OCTOBER-DECEMBER 2017

PUTTING PATIENTS AT THE CENTER OF CARE PHYSICIANS' COMPREHENSIVE ("WHOLE PERSON") KNOWLEDGE OF PATIENTS AND PATIENTS' TRUST IN THEIR PHYSICIAN WERE THE VARIABLES MOST STRONGLY ASSOCIATED WITH ADHERENCE, AND TRUST WAS THE VARIABLE MOST STRONGLY ASSOCIATED WITH PATIENTS' SATISFACTION WITH THEIR PHYSICIAN.

PRIMARY CARE PHYSICIANS PLAY A KEY ROLE IN ENCOURAGING HEALTHY LIFESTYLES.1 1

http://www.annfammed.org/content/6/1/6

WHERE HEALTH IS P

The United States spends twice that of o health care system, yet our health ranks spending so much and getting so little?

Research shows that for every dollar inv $13 in downstream costs to the system. doctor spend 30 percent less on health are less likely to suffer from cancer, hear high number of primary care doctors hav quality care.

We know that a strong foundation of prim and better health at lower costs to the s in America.

Learn more at healthisprimary.o Brought to you by America’s Family Physicians

PATIENTS’ TRUST AND COMMITMENT TO THEIR PHYSICIAN FAVORABLY INFLUENCE THEIR HEALTH BEHAVIORS, LEVEL OF SATISFACTION AND ADHERENCE TO A MEDICAL REGIMEN.1