The Neurology Issue

FP WINTER 2022

MISSOURI FAMILY PHYSICIAN VOLUME 41, ISSUE 1

NEUROLOGY issue

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FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION BOARD CHAIR John Paulson, DO, PhD, FAAFP (Joplin) PRESIDENT John Burroughs, MD (Kansas City) PRESIDENT-ELECT Kara Mayes, MD, FAAFP (St. Louis) VICE-PRESIDENT Afsheen Patel, MD (Kansas City) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS DISTRICT 1

DIRECTOR ALTERNATE DISTRICT 2 DIRECTOR ALTERNATE DISTRICT 3 DIRECTOR DIRECTOR ALTERNATE DISTRICT 4 DIRECTOR ALTERNATE DISTRICT 5 DIRECTOR ALTERNATE DISTRICT 6 DIRECTOR ALTERNATE DISTRICT 7 DIRECTOR DIRECTOR ALTERNATE DISTRICT 8 DIRECTOR ALTERNATE DISTRICT 9 DIRECTOR ALTERNATE DISTRICT 10 DIRECTOR ALTERNATE DIRECTOR AT LARGE

Arihant Jain, MD (Cameron) Mike Feuerbacher, MD (Maryville) Robert Schneider, DO, FAAFP (Kirksville) Vacant Emily Doucette, MD, FAAFP (St. Louis) Dawn Davis, MD (St. Louis) Lauren Wilfling, MD (St. Louis) Jennifer Scheer, MD, FAAFP (Gerald) Jennifer Allen, MD (Hermann) Natalie Long, MD (Columbia) Amanda Shipp, MD (Versailles) David Pulliam, DO, FAAFP (Higginsville) Justin Cramer, MD, FAAFP (Marshall) Beth Rosemergey, DO, FAAFP (Kansas City) Afsheen Patel, MD (Kansas City) Wael Mourad, MD, FAAFP (Kansas City) Andi Selby, DO (Joplin) Barbara Miller, MD (Buffalo) Douglas Crase, MD (Licking) Vacant Vicki Roberts, MD, FAAFP (Cape Girardeau) Gordon Jones, MD (Sikeston) Jacob Shepherd, MD (Lees Summit) Josephine Glaser, MD (St. Louis) Krishna Syamala, MD (St. Louis)

RESIDENT DIRECTORS Morgan Murray, MD, UMKC Wesley Goodrich, MD, UMKC (Alternate)

STUDENT DIRECTORS Kelly Dougherty, UMC Karstan Luchini, KCU Joplin (Alternate)

AAFP DELEGATES

CONTENTS 6 2020-21 Annual Reports 10 29th Annual Fall Conference 12 73rd Annual Business Meeting 14 Meet the 2021-2022 MAFP Board of Directors 16 Types of Aura 18 Outpatient Screening and Management of Dementia in Collaboration with Specialists 20 The Dizzying Facts of Concussions 23 Concussion Trends for Family Physicians: Are We Looking in the Right Place?

28 Pediatric Migraine: Little Brains, Big Pains 30 Wildwood Physician Named MAFP Family Physician of the Year 36 2021 Academy Awards Presented 38 Members in the News 41 References

MARK YOUR CALENDAR February 17 Spring Scientific CME Series (virtual) – Neurology www.mo-afp.org/cme-events/spring-cme/

Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Delegate Sarah Cole, DO, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

February 28 – March 1 Advocacy Day – Jefferson City & Virtual pg. 43 www.mo-afp.org/advocacy/advocacy-day/

MAFP STAFF

March 17 Spring Scientific CME Series (virtual) – Geriatrics www.mo-afp.org/cme-events/spring-cme/

EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE ASSISTANT EXECUTIVE DIRECTOR Bill Plank MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey The information contained in Missouri Family Physician is for informational 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 opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org

April 21 Spring Scientific CME Series (virtual) - Cancer www.mo-afp.org/cme-events/spring-cme/ May 19 Spring Scientific CME Series (virtual) – Musculoskeletal www.mo-afp.org/cme-events/spring-cme/ November 11-12 30th Annual Fall Conference - Big Cedar Lodge, Ridgedale MO-AFP.ORG 3

Caring for Neurological Patients

W John Paulson DO, PhD, FAAFP Board Chair, Joplin

elcome to 2022! Looking back on some of the most difficult times in medicine, many of us look to the future with hope and expectations of better times ahead. Personally, I am excited to gather together again. The MAFP board is also looking to the future. We are going to continue offering our members education through various delivery methods, advocate for family medicine at the State Capitol, and provide valuable member services. We are preparing to meet this Summer to update our strategic plan and to chart our course for the next 5 years.

This magazine focuses on Neurology. Recently, I was speaking to my local Neurologist. I don’t know about your town, but Joplin’s population is about 50,000 with a projected weekday population of over 250,000. We only have two Neurologists between both hospital systems. Like most family physicians, we adapt care based on the available resources and take care of our patients. Within this issue, you will learn about screening and management of dementia, a metareview of concussion and new tools to help diagnose them in your patients, the science of concussions, pediatric migraines, and types of headache aura.

Personally, I am looking forward to learning a little

more this month in the magazine that might allow me to care for a patient that I normally need to refer on to a neurologist. As you encounter these issues in your practice, it is the MAFP’s hope that this journal is helpful for you in caring for your patients.

As we move through 2022, I take comfort in knowing we have a curious membership that is consistently learning how to best care for all Missourians. I am confident in our membership delivering great care, engaging with MAFP, and enhancing the specialty of family medicine. I have had the distinct pleasure of becoming increasingly involved with MAFP and have had the pleasure of meeting many of our members over the last 14 years. Based on what I’ve seen from our board and my fellow family physicians, I look forward to another great year.

PS - The board will engage in a strategic planning session this summer and the MAFP staff is collecting stories from our members about why family medicine is so great to publish later this year. Please reach out to a board member or the MAFP staff with any thoughts about our organization or stories to share.

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MISSOURI FAMILY PHYSICIAN January - March 2022

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2022 Membership Needs Assessment Now Open Please take 14 minutes today to provide us with important information that will help guide the Academy for the next several years. Your input is truly appreciated and needed!

The information obtained from this survey will be used by the Missouri Academy of Family Physicians Board of Directors to determine how to allocate resources and best serve the membership. All responses are kept confidential. These results will also be used in the development of the 2023-2025 strategic plan.

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2020-21 Officer Annual Reports Jamie Ulbrich, MD, FAAFP Board Chair

Ten years ago, when I began my service on the Missouri Academy of Family Physicians’ board of directors, I knew I wanted to promote family medicine in Missouri and felt that I could make a difference. I did not anticipate the amazing journey and friendships that have formed along the way. We have worked together to improve the health of our patients, we have endured and are finding our way through the COVID-19 pandemic, and are preparing for the workforce of tomorrow. I hope we are better today than yesterday.

If I had to summarize my experience in one word, it would be enthusiastic. The MAFP board has enthusiastically carried out the strategic plan, even in uncertain times. Challenges were presented during a time when we didn’t know what each day would bring, but we were ready, willing, and able to adapt our programs and services to meet the needs of you, our members.

Despite all the differences among us being highlighted in the media, we are family physicians. The MAFP is the only organization that represents our unique specialty, education, and experience. Not only are we family physicians, but we also have one other characteristic in common, we have a voice. The MAFP members are passionate about promoting and protecting the practice of family medicine. As an organization, we may not always agree on a specific issue. Still, we all agree that we have to be active in our local communities, state legislatures and regulatory agencies, and our federal government to impact change.

Your MAFP has shared our voice with state leaders and federal agencies. We met with the new Missouri Department of Health and Senior Services director, Donald Kauerauf, to become a resource to him as he leads this multi-faceted statewide agency.

During the COVID-19 pandemic, we have submitted several letters to Governor Parson expressing concern with Executive Orders. We relayed the importance of the family physician in the diagnosis and treatment of COVID-19 patients. We fought for you, and specifically, the independent practicing family physician, to have access to the vaccine along with our employed family physicians.

This continued as the vaccine was being rolled out to priority groups and independent family physicians had access to the vaccine in smaller quantities for their patients.

During the 2021 legislative session, we opposed scope of practice expansion of our mid-level team members. We spearheaded and guided the team to educate our elected leaders 6

MISSOURI FAMILY PHYSICIAN January - March 2022

about the benefits of the preceptor workforce program. Although the measure didn’t make it across the finish line, we were one vote away and are confident that we can continue our enthusiastic legislative efforts during the 2022 session.

We must be doing something right. The MAFP has seen membership growth of active members by almost 10% since 2011. Total membership increased 26% during this same 10-year period which shows that our message to future family physicians is working through our programs and outreach presentations.

We extended the Strategic Plan to be completed in 2022 because some goals and initiatives were not on target due to the COVID-19 pandemic. It directs our efforts and programs to ensure we are meeting your expectations as well as planning for future family physicians. This plan has not been on a bookshelf as many are after they are written. This plan is our guide and the MAFP’s future. Please take a few minutes to look at this plan (on our website at: mo-afp.org) and provide feedback to the MAFP board or staff. As we begin the look to the future for the 2023-2025 plan, your vision and goals are critical for us to ensure we stay relevant to you and your practice.

As I ended my annual report last year, I continue to be honored and humbled to represent you during my tenure on the board.

The family medicine team will enthusiastically have a place at the table, express our voice on issues important to the practice of family medicine. Still, most of all, we will enthusiastically care for our patients, one at a time, one day at a time.

John Paulson, DO, PhD, FAAFP President

Personally, as I reflect on the last year of my personal and professional life, I see fear, conflict, and controversy all around. When writing this report, the data showed that 48% of Missourians had been fully vaccinated against COVID-19.

In the two counties I serve, it’s between 26% and 30%. I don’t see cost or access preventing vaccination, at least not where I practice in Joplin, MO. From where I sit, it appears to be the patient’s choice which physicians typically refer to as vaccine hesitancy. So, why are folks so hesitant? As most family physicians have probably done, I started asking and listening to patients, friends, and family. The short version of what I heard from all of them who were not vaccinated was fear. Some fear the vaccine; some fear losing their rights or freedoms; some fear the unknown; some just too paralyzed to decide because of overwhelming fear. Yes, some still lack the understanding of vaccine principles, herd immunity, and the usual vaccine education we have provided for decades. However,

2020-21 OFFICER ANNUAL REPORTS the core issue across the board with my people appears to be that they are scared.

Over the last several decades, physicians have changed from the paternalistic patient-physician relationship to what we now refer to as shared decision-making. This has been reported to develop trust between patient and physician, and it is one of the ways we reduce litigation risk. We share the objective risks and benefits with the patients, and they get to choose how much risk they are willing to accept for the potential benefit of the treatment. Anticipating that most physicians support immunization in general and likely recommend COVID vaccination for most people, how will potential conflict be handled when our patients choose a choice that we may disagree with?

I served about ten years in law enforcement before going to medical school and got to see firsthand how scared people behave when confronted. Defensive behaviors manifest in a variety of adaptive responses to perceived threatening situations and stimuli which the layperson would refer to as fear. I believe research demonstrates a significant link between fear and anxiety, most certainly from a psychopharmacology perspective. As we see a rise in depression, anxiety, and substance abuse during the pandemic, it just makes sense to me that fear is the condition that we have to address to heal and help our patients. I wonder if mandates and ultimatums are the best way to accomplish our goal or if they simply increase fear and anxiety that works against us.

What is the opposite of fear? According to a quick Google search, the opposite of fear can be a lot of things, trust, curiosity, courage, clarity, or calmness. So, I look to each of you to be creative, curious, and courageous in our fight against fear.

Continue to develop trust with your patients and learn to listen for them to reveal their true fears. Then and only then will you be able to address the source and begin the healing process with your patient.

Thank you for caring so much for each and every one of your patients. It has been such an honor to serve as the MAFP president over the last year, and I want to thank the membership for this opportunity. I would also like to thank Kathy, Bill, and Brittany for all their commitment, creativity, and curiosity! What a wonderful group of people to have at our side.

Here are a few initiatives that MAFP worked on during 2021 that have made us a stronger and trustworthy organization: • Various MAFP members participated in mass COVID vaccination events • Service on Missouri Advisory Committee for Equitable Vaccine Distribution • Worked to get vaccines into family medicine clinics in smaller quantities • MAFP team met with Don Kauerhauf, the new director of the Missouri Department of Health and Senior Services.

• Physician/Patient Relationship – Discussed the importance of the physician/patient relationship. A member reached out about an employer restricting prescribing rights for physicians and restricting physicians from providing vaccine exemptions to

patients despite guidance available on when that is appropriate.

This led to a discussion regarding physician practice rights being encroached upon by employers. It was noted that other third parties’ control how physicians practice, such as physician employers, insurance, and Medicare/Medicaid. It was agreed that we should support and defend the physician/patient relationship.

• Board of Director now has all director vacancies filled • Continued advocacy in regards to APRN scope of practice, assistant physicians, primary care investment, preceptor workforce program (preceptor tax credit), etc.

• Constant effort to continue to provide in-person meetings like the Annual Fall Conference, Transition to Practice conference, etc. The 2022 Advocacy Day is expected to be held in person, and we hope to see you there!

John Burroughs, MD President-Elect

The MAFP Board has continued to work diligently to move forward in serving family physicians throughout the state through another year of challenges and shifting climates. We continue to keep our efforts guided by the Strategic Plan developed in 2018 structured around a focus on Advocacy, Public Awareness, and improving the pipeline for growth in Family Physicians in Missouri. A major event in the coming year will be a summer review of the Strategic Plan and the creation of a new Plan to guide our efforts in the coming years. Our profession is made up of a beautiful and varied array of practices, so we need as many different voices as we can in this discussion. See how YOU can get involved in developing our new Strategic Plan and speak up!

2020-21 saw a restructuring of our Academy office in order to help us move forward in our goals and reach new heights in our reach and impact. Two new roles were created: an assistant executive director (Bill Plank) and member communications and engagement coordinator (Brittany Bussey). It has been remarkable how seamless this transition has proceeded despite the challenges of the COVID pandemic changing the way we gather (together and remotely) and disseminate education and information. Many thanks to our executive director (Kathy Pabst) for leading this transition (including having the vision to initiate it) and to Bill and Brittany for their skills, energy, focus, and adaptability in these ever-changing times.

The pandemic has certainly changed the way we meet for education and networking, still causing the cancellation of many of our annual meetings and conferences. It was still a thrill to participate (virtually) in our Missouri and national advocacy days, allowing us to directly meet with our state and national legislators to discuss topics important to our patients and our profession.

These summits continue to be highlights in my calendar. Please get involved. Our legislators and their teams know far less about MO-AFP.ORG 7

2020-21 OFFICER ANNUAL REPORTS the health issues that they fund and legislate than you would hope. One of our goals is to have each of our state legislators have access to the thoughts and knowledge of a family physician in their district, including their own family physician. Can you help?

Hopefully, 2022 will see a return of more in-person conferences to help regain the ability to network with other academies, board members, and family physicians across the region and the country.

We have also faced the challenge of how to provide effective, efficient, and affordable CME to our physicians. This has included changing our summer conference to more frequent, virtual CME opportunities. I was thrilled to give a presentation on Identifying Emotional and Social Trauma in our Office Practice during one of these sessions. Have you participated in one of these sessions?

How did it go? How can we improve on providing CME? We continue to tackle the question of how best to provide important information to, as well as receive, critical input from our members via e-mail, surveys, conferences, and journals. What is the best way to reach you? Let us know!

I look forward to spending the coming year serving as President of this wonderful Academy. Thank you, Jamie Ulbrich, for your service to the Academy over the past four years as you complete your year as Board Chair. Thank you, John Paulson, for your year representing our Academy so well as President as you transition to Board Chair. We, the MAFP, will continue to strive to support our members and our profession. We are dedicated to finding ways to increase our ranks of family physicians in Missouri while working to improve the satisfaction, workload, and effectiveness of our existing physicians to stem the loss of physicians in our state (and nation). Tall tasks, but we can do it with your help!

Kara Mayes, MD, FAAFP Vice President

This past year and a half have been an interesting one for all of us. With the COVID-19 pandemic, the whole world transitioned to doing many more things via remote platforms and fewer in-person meetings. Having my first year on the MAFP Executive Commission as your Vice President be amid a pandemic has added some challenges to learning the role. However, it has been an incredible learning experience so far, and I look forward to continuing to serve over the next few years.

While AAFP’s Annual Chapter Leadership Forum was cancelled in 2020, I was able to attend virtually in 2021. June 2020 brought our first virtual MAFP board meeting, but I was glad to meet in person for our board meeting in November 2020 at Big Cedar Lodge. Another new virtual experience for me was virtual advocacy. I attended MAFP Advocacy Day and AAFP’s Family Medicine Advocacy Summit in 2021 to represent MAFP to our elected officials and their staff. Virtual lobbying was a completely different experience than in-person but was still fun and impactful.

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MISSOURI FAMILY PHYSICIAN January - March 2022

The MAFP Executive Commission has continued to work with MAFP staff to move our strategic plan forward in between meetings of the full board. We participate in monthly video calls to address any issues that come up and plan for the future. We extended our last strategic plan for an additional year given the current pandemic, but I look forward to meeting in 2022 to develop our focus for the next several years.

One additional project I’ve been able to take on this year is working with a group from AAFP’s America Needs More Family Doctors initiative on a workgroup developing a test and competitive event for HOSA-Future Health Professionals. We hope to increase high school students’ exposure to family medicine as a career path with this test and event. As we all know, family medicine is one of the best careers out there, so it has been enjoyable to decide the best way to show that to students. We hope to expand this to include undergraduate students in HOSA at some point in the future.

I plan to continue to learn and grow through my time on the Executive Commission and look forward to helping improve your Academy next year!

Lisa Mayes, DO

Secretary/Treasurer

COVID-19 impacted the Missouri Academy of Family Physicians this past year as we projected a slight decrease in membership dues. Although we exceeded the budgeted amount, it is still less than preCOVID renewals. All things considered, MAFP continues to be financially sound as programs and services were offered in virtual formats. The investments have made some gains this year to help offset the lost revenue from membership dues.

MAFP policy required an audit of the 2020 financial records and organizational processes. I am pleased to report that there were no deficiencies found in the financial stability, operations, and processes. The next audit cycle will be for the year 2024.

The annual budget is based on the current 2019-2021 Strategic Plan. The board did approve extending the plan through 2022 due to the COVID-19 pandemic. As we push to complete the existing plan, we are already beginning to set the course for our next strategic plan.

The MAFP Board of Directors provides excellent oversight of the financial operations of the Academy and ensures our funds are used in the best interest of our members. And, continuing from last year, MAFP will continue to move forward with our strategic initiatives to further strengthen the organization.

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Our members have spoken loud and clear that they prefer inperson live education opportunities. As many chapters continue to hold virtual meetings and conferences, the Missouri Academy of Family Physicians learned from the 2020 Annual Fall Conference that we can host a safe conference. Leaning on lessons learned from previous events, discussion with other meeting planners, new industry standards, and a healthy dose of caution, MAFP held the 29th Annual Fall Conference November 12-14, 2021, at Big Cedar Lodge in Ridgedale, MO. Family physicians across Missouri and surrounding states showed they were ready to attend live in-person CME sessions as we had 191 family physicians, residents, students, and other health care professional attend this annual meeting. Moreover, our industry partners play a powerful role in making this conference possible, and their support was strong with 31 exhibitors and sponsors.

For those in attendance, MAFP continued best practices by placing hand sanitizer throughout the meeting space, providing masks for all attendees, offering color-coded bracelets indicating comfort level with being around others, consistent seating each day, and altering meal delivery to enhance safety protocols. In addition, we were able to hold a Family Health Foundation of Missouri fundraising wine pull in conjunction with a Family Fun event. The Family Fun event included cookie decorating, a house of cards building challenge, cornhole in the Conference Center Lobby, and even a firepit outside with s’mores. A 50/50 drawing was held with Dr. David Meece winning.

Dr. Meece generously donated his winnings back to FHFM. Between

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MISSOURI FAMILY PHYSICIAN January - March 2022

the wine pull and 50/50 drawing, $3,760.50 was raised for the Family Health Foundation of Missouri. This money goes to support medical students and residents in their journey to becoming family physicians. On behalf of the students and residents – thank you to all that donated!

The conference also included the MAFP Annual Meeting during our Saturday Lunch, which is further discussed on page 12.

Attendees were able to earn up to 13.5 hours of CME. Many thanks to the following speakers who presented.

Based on the evaluation responses, AFC attendees found these speakers and sessions highly valuable and relevant to their practice.

In addition to the expert lineup of speakers, MAFP held its annual meeting and installation ceremony at this event. We also recognized leaders among our members with our awards ceremony. More information on this event can be found on page 12-13. Save the Date – Our 2022 Annual Fall Conference will be held on November 12-13 at Big Cedar Lodge. The MAFP annual meeting will be held in conjunction with this conference.

Paul Ziajka, MD, PhD

Management of Hyperlipidemia in the Family Medicine Setting

David Norris, MD, MBA

Never Lose Another Negotiation – A System for Successful Negotiations

Kristin Sohl, MD, FAAFP

ABCs of ADHD: Diagnosis and Management

Keith Ratcliff, MD, FAAFP Peter Koopman, MD, FAAFP

2021 Legislative Update

Krishna Syamala, MD, FAAFP Kanika Cunningham, MD

Achieving Equity in Opioid Use Disorder: What Should We Do Now?

Ben Francisco, PhD Collective Impact – Clinical and Community Partners Move the Needle in Chronic Asthma Care Annie Rutter, MD, MS

Precepting and Teaching Family Medicine

Katie Davenport-Kabonic, DO

Walk With a Doc: Evidence for Physical Activity and Social Connectedness in Nature (including 7am walk!)

Jason G. Newland, MD, MEd

Strategies to Improve Antibiotic Use in Children

Josephine Glaser, MD, FAAFP

Overview of Chronic Kidney Disease and Disparities in Care

Lauren Wilfling, DO

Infertility Care by the Family Physician

Julie Rhee, MD Dana Day, MD

Critical Access Hospitals – How Critical are They?

Joshua Gilmore, MBA Joerg Ermann, MD

Overcoming Challenges in Diagnosis and Management of Axial Spondyloarthritis

THANK YOU TO OUR SPONSORS AND EXHIBITORS

ChenMed Citizens Memorial Hospital Labcorp

Missouri Child Psychiatry Access Project Somly DPC Clinics

Babylon Health Biohaven Pharmaceuticals Central Missouri Home Health Compass Health Network CoxHealth CoxHealth Bariatric and Metabolic Surgical Institute Defense Health Agency Civilian Medical Corps Docs Who Care Exact Sciences Jazz Pharmaceuticals, Inc.

Mercy Clinic Missouri Athletic Trainers Association Missouri Health Professional Placement Services Missouri Telehealth Network & Show-Me ECHO Novo Nordisk – Diabetes Novo Nordisk – Obesity PathGroup SmartVest by Electromed, Inc. Society of Teachers of Family Medicine Tobacco Free Missouri

73rd Annual Business Meeting The Missouri Academy of Family Physicians held its 73rd Annual Business Meeting during the Annual Fall Conference on Saturday, November 13, 2021, at Big Cedar Lodge in Ridgedale, MO. This meeting was held in conjunction with the Awards and Installation ceremony to recognize members with exceptional service to their patients as well as installing the 2021-2022 MAFP leaders.

Each officer provided an annual report that was available electronically to all members through the members only page on the MAFP website. You can view them on pages 6-8.

In addition, the MAFP bylaws amendments were approved and can be found on our website at: https://www.mo-afp.org/wpcontent/uploads/BYLAWS-AS-AMENDED-111321.pdf

We also took time to acknowledge and show respect for our fellow family physicians who passed away during the past year. A moment of silence was held to honor: William Leonard Fair, MD (Chillicothe) Donald Edward Kuenzi, MD (Kansas City) Jack Taylor Steele, MD (Manchester) The Degree of Fellow recognizes members who have distinguished themselves among their colleagues, as well as in their communities, by their service to family medicine, by their advancement of health care to the American people, and by their professional development through medical education and research. Fellows of the AAFP are recognized as champions of family medicine. They are the physicians who make family medicine the premier specialty in service to their community and profession. Being a Fellow signifies not only ‘tenure’ but additional work in your community, within organized medicine, within teaching, and a greater commitment to continuing professional development and/or research.

The following MAFP members were conferred by Russell Kohl, MD, FAAFP, AAFP Speaker, at the November annual meeting: Andi Selby, DO, Joplin Krishna Syamala, MD, St. Louis Margaret Day, MD, Columbia Kara Mayes, MD, St. Louis Barbara Miller, MD, La Russell Ngozi Wilkins, MD, St. Peters Michael Farris, MD, Loma Linda

MAFP cultivates leaders through service on the board, participation in AAFP governance and programs, and through Congratulations! For more information and details about continuing education. Our newly installed leaders for 2021-2022 are: becoming a Fellow, visit the AAFP website at https://www.aafp. org/membership/welcome-center/involve/fellow.html.

Board Chair – John Paulson, DO, FAAFP (Joplin) As the 2020-21 year came to a close, members expressed President – John Burroughs, MD, FAAFP (Liberty) appreciation for each other and the ability to again meet in person.

President Elect – Kara Mayes, MD, FAAFP (St. Louis) We hope you can join us as we prepare for our 75th Anniversary by Vice President – Afsheen Patel, MD (Kansas City) Secretary/Treasurer – Lisa Mayes, DO (term expires in 2025) developing a story book of family physicians. Share what impacted you to choose family medicine, how you have made a difference in (Macon) a student, resident, or patient’s life, or who inspired you to choose AAFP COD Delegates – Keith Ratcliff, MD, FAAFP family medicine.

(Washington) and Kate Lichtenberg, DO, FAAFP Submit your stories online by scanning the QR code: (Kirkwood)

AAFP COD Alternates –Peter Koopman, MD, FAAFP, (Columbia) and Sarah Cole, DO, FAAFP (St. Louis)

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MISSOURI FAMILY PHYSICIAN January - March 2022

Congratulations on Your Membership Milestone

You are vital to the success of family medicine in Missouri. This year, we celebrate the following family physicians who have achieved a milestone membership anniversary.

60 55

Years of Membership

George Richardson, MD, FAAFP, Sarasota, FL

Years of Membership

Wilbur Dabbs, MD, Neosho, MO Lee Heutel, MD, Saint Louis, MO L Silvers, MD, FAAFP, Lees Summit, MO

50

Years of Membership

Sally Hubbard, MD, Keytesville, MO Curtis Long, MD, FAAFP, Butler, MO L Magruder, MD, FAAFP, Nevada, MO Ruel Miciano, MD, FAAFP, Harrisonville, MO Earl Scott, MD, FAAFP, Bonnots Mill, MO

45

Years of Membership

Arnold Brody, MD, FAAFP, Evanston, IL David Brunworth, MD, FAAFP, Washington, MO George Klingner, Jr, MD, FAAFP, Springfield, MO Alejandro Ojascastro, MD, FAAFP, Saint Louis, MO Jimmy Presley, MD, Bolivar, MO Kenneth Scott, MD, FAAFP, Clinton, MO

40

Years of Membership

Jerald Chaffin, MD, FAAFP, Branson, MO James Conant, MD, FAAFP, Saint Joseph, MO Curtis Dyer, MD, Jefferson City, MO Wendell Elliott, MD, Poplar Bluff, MO James Felts, MD, Rolla, MO David Glover, MD, FAAFP, Warrensburg, MO Rashid Hamid, MD, FAAFP, Kansas City, MO Douglas Kenney, MD, FAAFP, Clinton, MO Jay Kimball, MD, Kansas City, MO Robert Kunkel, MD, FAAFP, Washington, MO Hsien-Ell Lai, MD, FAAFP, Rolling Hills Estates, CA Carl Ledbetter, DO, Kearney, MO Timothy Long, MD, Washington, MO William Miller, MD, FAAFP, Hermann, MO John O’Connor, MD, FAAFP, O Fallon, MO Ronald Phillips, MD, FAAFP, Kirksville, MO Richard Price, MD, Harrisonville, MO Andrew Scaduto, MD, Eureka, MO Anne Sly, MD, Kansas City, MO Gilbert Smith, MD, Poplar Bluff, MO Mark Suenram, MD, Kansas City, MO

35

Years of Membership

Stephen Adams, MD, Springfield, MO Rohn Allega, MD, Joplin, MO Michael Ausmus, MD, Lees Summit, MO Brian Basham, MD, Aurora, MO Gerianne Bliss, MD, FAAFP, Lees Summit, MO

Jayne Brockhaus, MD, FAAFP, Warrensburg, MO Steven Buie, MD, FAAFP, Raymore, MO Robert Buzard, MD, FAAFP, Excelsior Springs, MO Miguel Cannon, MD, Saint Louis, MO Darwin Davis, Jr, MD, FAAFP, Ellsinore, MO James DiRenna, DO, FAAFP, Kansas City, MO Janet Elliot, MD, Lohman, MO Joe Farley, , Springfield, MO Loretta Feeler, DO, Tebbetts, MO Cindy Fortado Clark, MD, FAAFP, Bridgeton, MO Gena Gardiner, MD, Saint Louis, MO William Gilbirds, MD, FAAFP, Kansas City, MO Marcia Graham, MD, FAAFP, Springfield, MO William Graham, MD, FAAFP, Springfield, MO Nathan Granger, MD, MBA, Kansas City, MO Gurprakash Grewal, MD, FAAFP, Saint Louis, MO Felix Herrera, MD, FAAFP, Saint Louis, MO Aubra Houchin, DO, Saint Peters, MO Christine Jacobs, MD, FAAFP, Saint Louis, MO Michael Jones, MD, Kansas City, MO Douglas Koehn, MD, FAAFP, Gravois Mills, MO Thomas Lord, MD, Weldon Spring, MO Harold Maxey, MD, FAAFP, Joplin, MO James Nahlik, MD, FAAFP, Chesterfield, MO Darryl Nelson, MD, FAAFP, Lees Summit, MO Steven Newbold, MD, Springfield, MO Mica Newman-Koehn, MD, FAAFP, Gravois Mills, MO John O’Brien, MD, Weldon Spring, MO Steven Radel, MD, Saint Peters, MO Keith Ratcliff, MD, FAAFP, Washington, MO Stephen Salanski, MD, FAAFP, Lees Summit, MO Robert Sawicki, MD, FAAFP, Lake Saint Louis, MO Alan Scharrer, MD, FAAFP, Lees Summit, MO Daniel Schmidt, MD, Richland, MO Ralph Schmitz, MD, FAAFP, Monett, MO Bruce Scully, MD, FAAFP, Grain Valley, MO Jeffrey Sharp, MD, FAAFP, Sedalia, MO Morton Singer, MD, Saint Louis, MO Jay Sparks, MD, Springfield, MO Stephen Staten, MD, Saint Louis, MO Stephen Stewart, MD, Venice, FL Terry Suppes, DO, Overland Park, KS Janet Theby, MD, Jefferson City, MO Rebecca Turner, MD, Raytown, MO Jeffrey Van Biber, MD, Lees Summit, MO Dane Wicks, MD, FAAFP, Kansas City, MO Johnna Wilcox, MD, Kansas City, MO Russell Yocum, DO, FAAFP, Kansas City, MO

30

Years of Membership

Brian Adkison, DO, FAAFP, Springfield, MO Debra Ahern, DO, FAAFP, Smithville, MO Kelly Bain, MD, Wildwood, MO Holly Benedict, MD, Nixa, MO Sally Bomar, MD, FAAFP, Maryville, MO Mark Brady, MD, FAAFP, Springfield, MO Scott Darling, DO, FAAFP, Kearney, MO Charolette Endsley, MD, Springfield, MO Susan Graves, MD, FAAFP, Republic, MO Debra Gupta, MD, FAAFP, Smithville, MO Kelly Hartel, MD, Potosi, MO Dale Haverstick, MD, Nixa, MO Laurain Hendricks, MD, FAAFP, Florissant, MO Shaun Holden, MD, Harrisonville, MO

Justin Jones, MD, FAAFP, Auxvasse, MO John Lautenschlager, MD, Florence, OR John Lowry, MD, MBA, Saint Louis, MO David Mehr, MD, Columbia, MO Scott Moose, MD, Nixa, MO Marta Mortensen, MD, Springfield, MO Timothy Murphy, MD, Saint Louis, MO David Nill, MD, Lake Lotawana, MO Jonathan Privett, MD, Sunrise Beach, MO Randal Qualls, DO, Lebanon, MO Steven Rettinger, MD, Shawnee, KS Cheryll Rich, MD, FAAFP, Poplar Bluff, MO Paul Rosenthal, DO, Lees Summit, MO Robert Schneider, DO, FAAFP, Kirksville, MO Steven Stahle, MD, Saint Louis, MO Tuongvan Tran, MD, Lees Summit, MO Teresa Troy, MD, SPRINGFIELD, MO Laura Vance, MD, Bolivar, MO Darryl Zinck, MD, Saint Louis, MO

25

Years of Membership

Michelle Barg, MD, Linn, MO Rebecca Baskins, MD, Kansas City, MO Joseph Beckmann, MD, Columbia, MO Julie Cahill, MD, Sedalia, MO Mark Chambers, MD, Springfield, MO Laurie Clarkston, MD, Willow Springs, MO Christopher Compton, MD, Jackson, MO Todd Craig, MD, FAAFP, Saint Louis, MO Robert Drogan, DO, Kansas City, MO Julia Flax, MD, FAAFP, Springfield, MO Brett Foersterling, MD, Saint Louis, MO Theresa Garcia, MD, FAAFP, Blue Springs, MO Kyle Griffin, MD, FAAFP, Springfield, MO Rachel Hailey, MD, FAAFP, Leawood, KS Amanda Heidemann, MD, FAAFP, Manchester, MO Denise Hooks-Anderson, MD, FAAFP, Saint Louis, MO Curtis Horstman, DO, West Plains, MO Heather Jordan, MD, O Fallon, MO Frederick Keenan, MD, Kansas City, MO Berent Krumm, MD, Leawood, KS John Lilly, DO, Springfield, MO Deborah Manning, MD, FAAFP, Kansas City, MO Barbara Miller, MD, FAAFP, La Russell, MO Ann Murphy, MD, Independence, MO Kevin Olson, MD, Lees Summit, MO Kwabena Owusu-Dekyi, MD, Saint Charles, MO Vani Pachalla, MD, Chesterfield, MO Payal Patel, MD, Saint Louis, MO Sequita Richardson, MD, FAAFP, Grandview, MO Alan Sandidge, MD, Barnhart, MO Thomas Sommers, MD, Saint Louis, MO Daniel Stahl, MD, Saint Louis, MO John Stein, MD, Saint Louis, MO Rishi Sud, MD, Chesterfield, MO Ingrid Taylor, MD, Shiloh, IL James Toombs, MD, Saint Louis, MO Dang Tran, MD, Saint Charles, MO Chad Voges, MD, Saint Peters, MO James Walker, MD, Kansas City, MO Sandra Zakroff, MD, Cape Girardeau, MO

MO-AFP.ORG 13

Meet the 2021 – 2022 MAFP Board of Directors Officers

John Paulson, DO (Joplin) Board Chair

John Burroughs, MD (Kansas City) President

Afsheen Patel, MD (Kansas City) Vice President

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Kara Mayes, MD (St. Louis) President-Elect

Lisa Mayes, DO (Macon) Secretary-Treasurer

Arihant Jain, MD (Cameron) District 1 Director

Mike Feuerbacher, MD (Maryville) District 1 Alternate

Robert Schneider, DO (Kirskville) District 2 Director

Dawn Davis, MD (St. Louis) District 3 Director

Emily Doucette, MD (St. Louis) District 3 Director

Lauren Wilfling, DO (St. Louis) District 3 Alternate

Jennifer Scheer, MD (Gerald) District 4 Director

Jennifer Allen, MD (Hermann) District 4 Alternate

Natalie Long, MD (Columbia) District 5 Director

Amanda Shipp, MD (Versailles) District 5 Alternate

David Pulliam, DO (Higginsville) District 6 Director

Justin Cramer, MD (Marshall) District 6 Alternate

Beth Rosemergey, DO (Kansas City) District 7 Director

Ed Kraemer, MD (Kansas City) District 7 Director

MISSOURI FAMILY PHYSICIAN January - March 2022

Wael Mourad (Kansas City) District 7 Alternate

Andi Selby, DO (Branson) District 8 Director

Barbara Miller, MD (Joplin) District 8 Alternate

Douglas Crase, MD (Licking) District 9 Director

Vicki Roberts, MD (Sikeston) District 10 Director

Gordon Jones, MD (Sikeston) District 10 Alternate

Morgan Murray, MD (UMKC) Resident Director

Wesley Goodrich, MD (UMKC) Resident Alternate

Kelly Dougherty (UMC) Student Director

Karstan Luchini (KCU) Student Alternate

Keith Ratcliff, MD (Washington) AAFP Delegate

Kate Lichtenberg, DO (Kirkwood) AAFP Delegate

Peter Koopman, MD (Columbia) AAFP Alternate

Sarah Cole, DO (St. Louis) AAFP Alternate

Jacob Shepherd, MD (Lees Summit) At Large Director

Josephine Glaser, MD (Fenton) At Large Director

Krishna Syamala, MD (St. Louis) At Large Director

District 2 and District 9 Alternate Director positions are vacant. If you are in these districts, volunteer to serve on the board!

MO-AFP.ORG 15

TYPES OF AURA

Breaking down the different types of aura your patient with migraine might experience By: Kathleen Digre, MD, FAHS American Headache Society

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MISSOURI FAMILY PHYSICIAN January - March 2022

Kathleen Digre, MD, FAHS, breaks down the types of aura and treatment considerations for each type. Dr. Digre is a distinguished professor of neurology and ophthalmology and director of the Headache Clinic at the University of Utah. She is also the immediate past president of the American Headache Society and a former president of the North American Neuro-Ophthalmology Society.

M

igraine with aura occurs in about one-third of people with migraine. The typical aura starts gradually over 5 minutes and lasts 5-60 minutes, is usually unilateral, and is followed by a headache within 60 minutes.

THE THREE TYPES OF MIGRAINE AURA

There are three major types of aura: visual, sensory and aphasic. Visual aura is the most common and accounts for 90% of all auras.

THERE’S NO SUCH THING AS OCULAR MIGRAINE Visual aura can present as seeing spots, zig-zags, flashes, or even losing sight for a short time. Even though visual aura is the most common, it can still confuse both patients and providers because it can be difficult to tell if it is occurring in one or both eyes. A true aura will usually be in both eyes because it comes from the brain. Most visual auras happen in the occipital

lobe, where a cortical spreading depression causes a small defect that gets bigger and bigger.

Sensory aura starts in the fingers and mouth, and it can spread, or it can just be a tingling sensation. Sometimes it can be a sensation on one side of someone’s body. As visual aura, it’s usually a slow and progressive onset.

Aphasic aura is rare, and it presents with speech difficulty. “So they can’t think of the words they want to say, or the words come out wrong,” says Dr. Digre. As with visual and sensory aura, it usually features a slow buildup followed by a headache.

HOW TO DIAGNOSE AURA

Dr. Digre usually starts by asking a patient to draw their aura for visual aura. “Those drawings could be so helpful to actually see what people are actually experiencing,” she says.

These drawings can also help pinpoint where it’s coming from. “If they draw their aura and you see a nice zig-zag pattern, there’s nothing in the eye that’s going to give you a zig-zag pattern,” Dr. Digre says. “Even if they say it’s only in my right eye, it’s going to be out of the brain.”

Dr. Digre often sends patients home with an Amsler grid, a tool used to detect visual problems and ask them to look at it with both eyes open and then covering each eye individually. “If they see that disturbance on the page when they’re looking at the book from both eyes, then you know it’s probably coming from the occipital lobe,” she says. This means it’s likely aura.

However, if the patient only sees the disturbance when looking at the page with one eye, it could be due to something happening in the retina or the visual system, like a vascular event. In this case, more testing should be done to determine the cause.

Diagnosing sensory and aphasic auras can be a little trickier, Dr. Digre says, but can be done through a thorough medical history, ruling out other causes and doing imagine when necessary.

IS IT AURA OR SOMETHING ELSE?

An extensive workup is not usually necessary unless your patient has an atypical aura (prolonged aura, an aura with abnormal or a lot of features, or an aura with loss of consciousness). Doing an MRI, for example, can rule out a stroke or brain tumor.

Several conditions are often confused with migraine aura, but some key differences can help determine if your patient has aura or something else.

Stroke can commonly be a concern for migraine patients experiencing aura, especially for those who experience aphasic aura with speech problems.

Stroke is usually maximum onset right at the beginning. Dr. Digre also says that stroke usually presents with negative phenomenon (complete loss of vision) instead of positive phenomenon (flashing lights in the eye).

However, Dr. Digre says people with migraine with aura have a slightly increased risk of stroke. That means providers should be vigilant about blood pressure, cholesterol, and other preventative factors to keep people from having strokes. Women with migraine with aura might want to consider not using oral contraceptives because that can also increase stroke risk.

Other conditions that can be confused with aura include occipital lobe epilepsy, which can come with visual symptoms but is actually a little seizure in the occipital lobe, and retinal migraine, which is a blindness that occurs in one eye and can have a fairly abrupt onset. Retinal migraine is extremely rare, affecting less than 1% of people, and is difficult to diagnose.

Dr. Digre says some providers call anything with visual disturbances ocular migraine. “There’s no such thing as ocular migraine,” she says.

Publication Note: This information will also be covered in our February 17 Virtual CME dedicated to Neurology.

We can also reference additional resources from AHS that can be found at https://americanheadachesociety. org/primarycare.

MO-AFP.ORG 17

Outpatient Screening and Management of Dementia in Collaboration with Specialists

A

Mercy Bowen, OMS2 Kansas City University-Joplin

Farhana Faruk, OMS2 Kansas City University-Joplin

Mariam Akhtar, MD Kansas City University-Joplin

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MISSOURI FAMILY PHYSICIAN January - March 2022

pproximately 50 million people globally are affected by dementia, though this number is expected to triple by the year 2050 as the aging population increases (Livingston et al., 2020). Dementia is a complicated disease state with no cure and thus requires a multidisciplinary approach for the best outcomes.

While family physicians hold a prominent role in dementia diagnosis and management in the United States, in this article, we will discuss the need for more involvement from neurologists and psychiatrists to have accurate and precise screening, diagnosis, and treatment of dementia.

Dementia is a progressive deterioration in a person’s memory and cognitive function as a result of neurodegenerative and non-neurodegenerative processes. There are four categories of dementia based on underlying pathophysiology: Alzheimer’s dementia (AD), vascular dementia, Lewy body dementia, and frontotemporal dementia. There is often overlap between these categories. Ultimately, they all culminate in the impaired ability to perform activities of daily living and maintain independence (Larson, 2019).

Dementia screening occurs in the outpatient setting using multiple screening tools administered by family physicians. Early screening is important because progression can be slowed through the management of risk factors such as with vascular dementia (Vicario et al., 2018). However, the United States Preventative Services Task Force (USPSTF) does not endorse or suggest against routine screening of patients without complaints of cognitive impairment (Larson, 2019). There are many questionnaires and screening tools that can be used to detect dementia in the outpatient setting. An acceptable screening tool is one that is sensitive and specific, appropriate for use in elderly people, quick and easy to administer and interpret. The Mini-Cog, Memory Impairment Screen (MIS), and General Practitioner Assessment of Cognition (GPCOG) are commonly used by primary care providers since they can be administered in less than five minutes. Despite the time convenience, it is important to note their decreased sensitivity and specificity: Mini-Cog (sensitivity and specificity of 76% and 73%), MIS (sensitivity and specificity of 43% and 93%), and GPCOG (sensitivity and specificity of 89% and 61%) (Abd Razak et al., 2019; Iatraki et al., 2017). Though these brief screening tools are not as sensitive at detecting early cognitive deterioration, they are still acceptable initial screening tools to be used by primary care providers. If a patient’s score is within normal limits and the primary care provider still suspects impaired cognition, then the patient can be further evaluated with any of the following comprehensive screening tools. The Mini-Mental State Examination (MMSE) is widely used, but it takes approximately 10-15 minutes to administer. It assesses a person’s orientation, memory, attention, language, and visuospatial function with a score less than 23 out of 30 considered abnormal (Mendez, 2019). In addition to the components tested by the MMSE, the

Montreal Cognitive Assessment (MoCA) also has the Clock Drawing Test, which has been shown to detect early signs of dementia in those at risk (Vicario et al., 2018). In a systematic review, the MoCA boasted a sensitivity and specificity range of 81-97% and 60-86%, respectively (Abd Razak et al., 2019). Addenbrooke’s Cognitive Examination III (ACE-III) is more comprehensive than the abovementioned tests. Studies have shown sensitivity as high as 100% and specificity of 96% with a score less than 81/100 as the cutoff (Abd Razak et al., 2019). This is the recommended screening test given the high sensitivity, but the time constraint limits its use by primary care physicians. Additionally, many general providers have difficulty interpreting the results; therefore, a specialist can be enlisted in the interpretation of the results if needed (Abd Razak et al., 2019). Thus, these two issues of time constraints and difficulty in interpretation of comprehensive screening exams highlight the need for specialist involvement, especially in the initial screening phase.

A recent survey found that while family physicians felt comfortable at diagnosing dementia through established cognitive tests of MMSE and Mini-Cog, they did not feel the same confidence (20% of family physicians vs. 68% of specialists) using newer cognitive screens that are more specific for cognitive domains and thus more useful in differentiating between a vast array of neurocognitive disorders that present with dementia-like symptoms (Bernstein et al., 2019). Moreover, in this same survey, family physicians also felt less comfortable with the appropriate use and interpretation of neuroradiology imaging to make a precise dementia diagnosis (14% confidence in family physicians vs. 69% of specialists) (Bernstein et al., 2019). These difficulties in precise dementia diagnosis are also highlighted in a separate study, where a diagnosis of unspecified dementia was higher amongst nonspecialists than specialists (Drabo et al., 2019). Research has found that early diagnosis of mild cognitive impairment is vital to the prognosis of dementia and that it is important to ascertain accurate etiology behind the clinical manifestation of dementia, as some forms of dementia are treatable or have therapeutic modalities that can significantly increase quality of life (Cooper & Greene, 2005).

Thus, a neurologist is critical in the precise assessment of dementia subtype and its staging and severity to better inform a family physician on appropriate management.

Family physicians are not only involved in the initial screening of dementia but play a prominent role in dementia management.

Dementia management is multi-pronged and involves a biopsychosocial model of care that includes both pharmacologic and nonpharmacologic therapy. Current pharmacological treatment of dementia revolves around the use of cholinesterase inhibitors such as donepezil and galantamine, as well as neuropeptide modifying agents like memantine. While studies have shown that these drugs significantly increase performance on the MMSE and other scales, this effect has not been shown to carry over to clinical improvement (Qaseem et al., 2008). Thus, it is not surprising that nonpharmacologic methods are recommended as the initial treatment for dementia. This includes therapies such as cognitive behavioral therapy, reality orientation, validation therapy, and reminiscence therapy (Douglas et al., 2004). Studies have also suggested that art/music and aromatherapy may also be useful adjuncts in dementia treatment, which highlights the need for practitioners trained in these therapeutic modalities to play prominent roles in dementia management (Douglas et al., 2004).

While these non-pharmacologic therapies have shown success in behavior modification and increases in quality of life, they have

minimal effects on the progression and pathology of dementia (Douglas et al., 2004).

Along with impairments in cognitive function, dementia also presents with a significant psychiatric disease burden which includes depression, aggression/agitation, hallucinations, and psychosis.

Studies have suggested that these diseases may have reciprocal and contributory actions upon each other, thus highlighting the need for psychiatric care in dementia management (Valero et al., 2020; Kales et al., 2014). Many family physicians have voiced that there are substantial barriers to non-pharmacologic therapy in a primary care setting, which may lead to increased use of pharmacologic therapies due to ease and efficacy (Kales et al., 2014). Psychiatrists can relieve this burden on family physicians in multiple ways. Psychiatrists are uniquely positioned to perform non-pharmacologic therapies like reminiscence therapy, validation therapy, and cognitive training and rehab. Moreover, studies have shown that psychiatrists can play an important role in training caregivers on behavioral interventions to reduce neuropsychiatric symptoms in dementia patients as well as decrease stress and burnout in caregivers (Kales et al., 2015).

Because there is only off-label use of pharmacologic therapies in treatment of neuropsychiatric symptoms in dementia, nonpharmacological therapies that are in the realm of psychiatrists may be more beneficial, and demonstrate an increased need for collaboration with a psychiatrist for dementia treatment (Kales et al., 2015).

While evidence points to the valuable role that neurologists and psychiatrists can play in the management of dementia, there are significant barriers to the use of these specialists for dementia patients. For example, there is a limited number of specialists in the US, and this leads to difficulties with follow-up care. Studies have suggested that telemedicine can fill in the gap and connect physicians and patients, allowing for more comprehensive management of dementia. One study in Southern California saw a 2-3-fold increase in dementia patient follow up with neurologists and neuropsychologists with the Memory Assessment Center Model (MAC) (Tso et al., 2016), while another study showed positive results with medication management using TeleDementia for rural populations (Chang et al., 2018). However, it is important to note that telemedicine also has its own barriers to care – many dementia patients have various forms of sensory loss, such as hearing loss or blindness. Additionally, patients and their caregivers may not have access to or knowledge about technology. While there appear to be initial benefits in telemedicine for dementia care, more research is needed to understand how to best implement this model.

Dementia is a devastating neurodegenerative condition affecting millions of people worldwide. Family physicians are key in using brief screening tools for the initial assessment of cognitive decline in patients they suspect of having dementia. However, once an initial diagnosis has been made, collaboration amongst family physicians and specialists, such as psychiatrists and neurologists, is key to the successful management of dementia patients. Neurologists are vital for a more rigorous and comprehensive diagnosis of dementia, and psychiatrists’ expertise in non-pharmacologic treatment of dementia is useful. Telemedicine is effective in bringing family physicians, neurologists, psychiatrists, and patients together.

Though there are limitations to the use of telemedicine, it allows for continuity of care, especially in the rural setting where specialist access might be difficult.

MO-AFP.ORG 19

The DIZZYING Facts of Concussions A

Kevin Munger, DO, MSA, CAQ-SM Blue Springs, MO

Christopher Fox, MD, CAQ-SM Blue Springs, MO 20

MISSOURI FAMILY PHYSICIAN January - March 2022

concussion is a mild traumatic brain injury caused by mechanical forces that get transmitted to the brain. This force can be either a direct injury to the head or can be from forces transmitted to the brain from other parts of the body. Concussion usually has rapid onset of neurological symptoms that resolve spontaneously. These symptoms can start minutes to hours after the injury4. Symptoms typically resolve in about 17 to 28 days for children and 7 to 14 days for adults.

Symptoms lasting greater than four weeks in a child or greater than two weeks in an adult are considered post-concussion syndrome.

About 80% to 90% of concussed patients will recover in these time frames7,19. The pathophysiology of concussions is complex, and our understanding has evolved over the last several decades16. There are many tools that can help aid in the diagnosis of concussion.

Ultimately, diagnosis is based on symptoms and physical exam.

Diagnostic tools should be used as an adjunct to your clinical findings. Treatment is largely relative rest, but there are directly supervised active therapies that can improve symptoms quickly.

Pathophysiology of a Concussion

The pathophysiology is complex with multifactorial process involving neurometabolic changes, ionic fluxes, direct cellular damage and blood flow regulation.

When a significant force is transmitted across the neurons to result in a concussive injury, the plasma membranes become permeable resulting in an outflux of potassium and influx of calcium. This results in depolarization of the axons and initial diffuse axonal depression16.

Glutamate is released from the injured cells which promotes potassium influx back into the cells. This can promote a feedback loop of hyperexcitability and depression of the neurons, causing cell damage and inhibition of cellular energy production by the mitochondria. This can normalize in 72 hours to 14 days in certain parts of the brain16. Acutely following a concussion, there is also an increased need for cellular energy, which can strain cellular mitochondria.

Studies have shown an acute increase in glycolysis followed by glucose hypometabolism and increased anaerobic energy production, leading to increased intracellular lactate levels16, 21. Research shows decreased regional blood flow in the brain following a mild traumatic brain injury (mTBI). A recent study using MRI-based measures of cerebral blood flow at seven days post-injury demonstrated regional blood flow is decreased to the frontal and temporal regions of the brain involved in autonomic processing and emotion regulations2. This decrease in blood flow also limits the supply of glucose to already depleted mitochondria resulting in a mismatch of metabolism and energy requirements. Data on this has been better understood in severe TBI; however, more evidence is showing this cascade is also involved in mTBI16, 2. There can also be direct injury to the neuronal axons from the shear force resulting in the concussion. This is seen more in severe TBI. However, this direct injury is believed to be on a spectrum and is also involved in pathophysiology of concussions17.

Another important concept involving the pathophysiology of a concussion is the period of vulnerability following a concussive injury. Research has shown that the mismatch between

energy availability and alterations of blood flow following a concussion can set up a “window of vulnerability,” in which the athlete would be more susceptible to a repeat injury. This could include a lowered force threshold for repeat injury, but also more significant and longer-lasting symptoms to even permanent neurologic deficits. Studies have shown this window likely follows the recovery of the energy availability and the normalization of cerebral blood flow, which occurs around seven days following the injury20.

Diagnosis of Concussion

Concussions are clinical diagnoses based on reported symptoms and clinical exam. Concussion symptoms can be observed such as loss of consciousness, impact seizure, slow to get up from a hit, stumbling, trips/falls, disorientation, vacant look, amnesia, clutching of head after contact and/or visible facial injuries. Symptoms can also be reported, such as headaches, dizziness, balance difficulties, nausea, amnesia, and light/sound sensitivity4. Recognizing some of these subtle symptoms of concussion can be difficult.

Immediately after an injury, the Standard Concussion Assessment Tool Fifth Edition (SCAT5) can be a useful tool to help identify a sports-related concussion on the sidelines. SCAT5 is less effective for aiding in the diagnoses of concussion 3-5 days after injury. SCAT5 is developed for rapid assessment of sports-related concussions, and it can be completed in under 10 minutes. SCAT5 is for ages 13 and older. Child SCAT5 is for ages 5-12. SCAT5 has a graded symptom score and tests balance as well as multiple cognitive systems3. SCAT5 does have a moderate to high reliability on test and retest of baseline6. This means that any deviation from baseline scores are likely to be a concussion. SCAT5 is intended to have baseline testing prior to a sports season starting. If you do not have a baseline SCAT5 on a patient, you can use serial SCAT5 measurements to track progression of concussion. However, you should not rely on SCAT5 alone to monitor a concussion to resolution.

The Post Concussion Symptom Scale (PCSS) can be used to monitor treatment progress. PCSS is a questionnaire of 22 graded items for a max score of 132 and takes about 5 minutes to complete9. Serial PCSS can be used to monitor reported symptoms of concussion to a patient’s baseline. It is important to remember that a patient’s baseline may not be a score of 0.

PCSS on baseline testing and re-baseline testing has been shown to have some variability in some study participants13. Using additional tools can help aid in the monitoring of treatment progress of patients.

The Vestibular/Ocular Motor Screening (VOMS) is another tool that can be used to assess concussion. Dizziness and balance problems are reported in 50% and 40% of sportsrelated concussions, respectively, and these symptoms may represent vestibular system involvement. The vestibular system is a complex system that includes the vestibulo-ocular system and the vestibulospinal system. The vestibulo-ocular system is responsible for visual stability during head movements, and the vestibulospinal system is responsible for balance. VOMS is a physical exam of the vestibulo-ocular system that is done while monitoring for provocation of concussion symptoms: headache, dizziness, nausea and fogginess14. VOMS is shown to have an excellent internal consistency (alpha=0.99), positive predictive value of 0.899 and a high sensitivity14. VOMS is not studied for MO-AFP.ORG 21

sideline use, so it is best used for assessment and monitoring after acute injury.

To test the vestibulospinal system, the modified Balance Error Scoring System (mBESS) is commonly used. mBESS is a series of balance positions that can be completed in a few minutes. mBESS has a poor internal consistency (alpha=0.29), and has a poor-to-moderate test-retest reliability9. When combining VOMS and mBESS you can effectively test the vestibular system in a few minutes and get a complete evaluation.

Laboratory testing to date has yielded limited results in regards to the diagnosis of concussions. Several blood biomarkers of traumatic brain injuries have been identified looking for signs of neuronal or axonal damage. These have been analyzed by looking at both blood and cerebrospinal fluid.

These markers include proteins such as neuron-specific enolase (NSE), total tau (T-tau), glial fibrillary acidic protein (GFAP), and S100B15. Studies have shown increased markers including S100B and tau in sports-related concussions as soon as 3 hours post-injury. However, the utility of these tests is limited as the levels have also been shown to increase in a linear fashion from sub-concussive hits such as headers in soccer15. At this time, continued research in this field is needed, and the best diagnostic tools for a concussion remain clinical.

Computerized neurocognitive tests (CNT) such as the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) are designed to test many brain functions (memory, attention span, visual and verbal problem solving). These tests require a baseline test. After baseline testing, then the concussed patient can be retested to help determine if concussion has improved or resolved. It is currently estimated that 33% to 39% of athletic trainers utilize CNT to determine return to play for their athletes. These tests are questioned on their clinical utilization. ImPACT has low reliability of 0.22.

Reliability is low when there is a change of scores on testingretesting study subjects without concussion. This leads to a false-positive rate of 38% for diagnosis of concussion. More alarming is the false-negative rate of 17%. This high falsenegative rate can put an athlete at risk for further injury or worse5.

Treatment of Concussion

Immediate recognition of a concussion is important for patients. Returning to activities with an active concussion can put patients at risk for worsening symptom burden, worsening injuries and longer duration of symptoms. “Second Impact Syndrome” is the rare and controversial potential lifethreatening complication of sustaining additional trauma to the brain while recovering from current concussion7. Because repeated head trauma can have serious consequences, it is important to remove a patient from high-risk head trauma activity immediately even if concussion is suspected and not formally diagnosed at that time.

Rest is the mainstay of concussion treatment. Total rest in a dark, quiet room has been shown to slow recovery.

Consensus guidelines support 24-48 hours of symptom-limited cognitive and physical rest followed by gradual return to normal activities7. An example is allowing a high school student athlete to have their mobile device, but counsel that as soon as concussion symptoms start to flare, athlete should put the phone down. The athlete can resume using the mobile device 22

MISSOURI FAMILY PHYSICIAN January - March 2022

as soon as concussion symptoms improve.

Sleep is important to brain recovery. A random controlled counterbalanced crossover study showed a statistically significant increase in symptom burden on PCSS in teenagers with mild sleep deprivation of 6.5 hours at night. The increased symptom burden returned to baseline with normal duration of sleep1.

Active treatments of concussion such as vestibular therapy and a prescribed sub symptom threshold exercising have shown to help with resolution of concussion. In a randomized controlled trial, participants with prolonged concussion symptoms (defined as ten days) are shown to be 3.91 times more likely to be cleared for activity when compared to no therapy intervention18. A directly supervised sub symptom threshold exercise program, often referred to as Buffalo Concussion Treadmill Testing (BCTT), has been shown to significantly reduce time to recovery in patients with postconcussion syndrome11. Additional studies have shown that BCTT can be done safely 2-4 days after sustaining a concussion in adolescents. BCTT in the acute phase did not worsen symptoms, but BCTT in the acute phase did not hasten recovery10. It appears the best active rehabilitation is vestibular therapy and BCTT starting about two weeks after sustaining concussion. Exercise has shown to improve cerebral blood flow, improve dysautonomia, improve CO2 sensitivity and improve brain derive neurotoxicity factor gene upregulation7.

Disqualification from activity is a tough subject with no evidence-based guidelines. This decision is multifactorial and includes consideration of individual tolerance of risk, number of concussions, length of recovery from concussions, severity of subsequent concussions, and consideration of long-term health. Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is characterized by behavioral change in patients with a history of repetitive head trauma. The current incidence is unknown due to our current limitations in technology to detect axonal injury and neuronal injury from repetitive subconcussive impacts and concussion. It is unknown if tau deposition is the cause of CTE or the byproduct of CTE. It is unknown if CTE is a progressive disease. Postmortem CTE changes have been seen in asymptomatic patients, and a cause and effect between CTE changes and behavioral/cognitive symptoms have not been demonstrated. This is an area of further research7.

CONCUSSION TRENDS FOR FAMILY PHYSICIANS: Are We Looking in the Right Place?

C David Voran, MD Platte City, MO

oncussions represent a small fraction of ambulatory family practice visits but concussion sequalae, including mild-to-moderate traumatic brain injury (TBI) may play a role in many visits. Concussion awareness has increased significantly over the last decade, especially in high contact sports, like rugby, hockey, American and European football as well as activities not traditionally considered sports, like cheerleading.

This awareness resulted in many changes in rules, helmet design, and protocols designed to minimize the frequency and improve MO-AFP.ORG 23

Figure 1. Ambulatory Concussion-Related Visits

skateboarding, skiing, and hockey leading to a 50% the diagnosis and treatment of concussions. However, decrease in emergency room visits for these type of for the family physician, accidental falls among seniors represents the largest cohort with these symptoms. This injuries. There has also been a corresponding 32% reduction in Emergency Department visits for contact article looks at both research and public search trends sports-related head injuries. According to the CDC, and compares them to the author’s own system to see whether national trends are reflected in the population seen by University Health/ Truman Medical Centers. In addition, a new source of patient self-reported data is explored to see whether that would help physicians diagnose and manage symptoms associated with head injuries.

Public awareness of concussions has increased since Dr. Bennet Omalu published his findings connecting concussions with chronic traumatic encephalopathy (CTE).

This discovery was directly responsible for rule changes in American Football limiting targeting and other football techniques that risk head injuries. In addition, public awareness has led to increased use of helmets when engaging in many activities such as bicycling, Figure 2. Number of Concussion Related Visits by Venue 24

MISSOURI FAMILY PHYSICIAN January - March 2022

Figure 3. Google Trends graph of relative interest over time in “concussions”, “traumatic brain injury”, and “head injury”

there were approximately 223,050 traumatic brain injury (TBI) related hospitalizations in 2018 and 60,611 TBI-related deaths in 2019. Another CDC surveillance report showed a decrease in hospitalizations from 2016 to 2017 with unintentional falls accounting for nearly half of all of these hospitalization.

Unfortunately, the same surveillance report showed seniors had the highest hospitalization rates for TBIrelated injuries in 2017 with those aged 75 with nearly triple the rate (320.8/100,000) of the next lower age group (102.7/100,000). These reports suggest progress being made in reducing head injuries in sports but maybe not so much among the elderly. Does this match our own experience and data within our electronic health records?

To answer this and other questions, custom report queries of University Health/Truman Medical Center’s electronic health records (EHR) were generated.

Additionally, Google Trends was used to see if the public’s searches matched the scientific reports mentioned above. These sources of information should help prepare family physicians to diagnose and answer questions for the patients they are seeing and likely to see.

Finally, a new source of information is being made available to physicians that was not easily obtained before 2021. That source of information comes directly from the patient. Patients now have access to smart phone apps that aggregate an increasingly broad set of data flowing from smart phones, Bluetooth enabled fitness trackers, watches, scales, beds, consumer ECGs and even clothing. Patients can access these apps and are now being offered the ability to share this data with their physicians. This self-reported data is viewed using physician dashboards available in a number of electronic health record systems. Early experience with this new source of information has already anecdotally helped the physician diagnose concussions or postconcussion sequelae and answer specific patient questions at the point of care.

First, EHR queries did show the frequency of all ambulatory visits have remained constant since 2019 (Figure 1) These reports also showed family physicians, as a

group, choose a much wider range of ICD10-CM codes when making their diagnoses than any other physician group. Over the last 3 years, University Health primary care physicians choose over 7,400 unique ICD10-CM codes compared to other specialties which typically utilize less than 1,000. In the same time period, skull and facial fractures, concussions, and traumatic brain injury ICD10-CM diagnoses (S02.0, S2.1, S06.xxx, S07.1) accounted for only 430 of the 216,629 of the primary care encounters in the University Health System (0.2%). Despite these low numbers, family physicians see more concussions in their clinics than any other group of physicians except surgery and emergency medicine physicians (Figure 2).

A search on “concussions”, “traumatic brain injury”, and “head injury” was initiated on Google Trends over the last 5 years to see whether public searches using these three terms matched the drop in incidences observed in the scientific literature. Figure 3 shows the native output of this search.

Notice the curious spike that occurred on January 17, 2020, the day Patrick Mahomes sustained a concussion in the Super Bowl. Figure 4 grouped the same data by quarter that paints a different picture showing a gradual decrease in searches for “concussions” roughly matching the scientific findings but more narrowly defined “TBI” and “Head Injury” searches remained relatively constant.

In response to real-world events, family physicians can utilize search engine queries to help predict when

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MO-AFP.ORG 25

Figure 4. Concussion related Google Searches per Year

patients may appear with questions that might come up, particularly if they are experiencing symptoms of a medical condition in the news.

There is a totally new source

PATIENTS CAN NOW SHARE ANY DATA IN APPLE HEALTH WITH OTHER PEOPLE INCLUDING THEIR PHYSICIANS 26

MISSOURI FAMILY PHYSICIAN January - March 2022

of information that most family physicians and patients are not yet aware. It is highly likely a significant number of patients are using or wearing devices that already are tracking an increasing number of vital signs, activities, and behaviors that relate directly with their medical conditions.

Seventy-six percent of University Health/Truman Medical Center’s active portal accounts are using mobile devices and 50% are using Apple’s iPhones with the remainder using one of many types of devices running one of several Android software versions.

Apple Health, a native iOS app on all iPhones is an application that can be configured to communicate with many other applications and devices including fitness trackers, watches, scales, thermometers, home blood pressure monitors, and consumer EKG devices (such as Kardia from AliveCor). Once

configured, the data continues to accumulate passively with little active involvement of the user who, at any time, can review aggregate information using a simple, easy to understand user interface.

What most users are not aware of is this same app can be configured to download a host of information from over thousands of hospitals, clinics, and labs if the user has an active patient portal that has been connected to Apple Health. Unfortunately, very few physicians and patients are aware of this capability. With the most recent iOS 15.x upgrade, patients can now share any data in Apple Health with other people including their physicians using the same patient portal conduit if the organization enables this interface.

Enabling this feed creates a physician dashboard of data the patient has chosen to share with the physician that is very easy to navigate.

Figure 5. Physician Dashboard for Apple Health

Recently, a patient presented to the clinic complaining of vague headaches and mild disorientation. He had enabled this feed and religiously worn his Apple Watch. During the review information with the patient, both the patient and physician uncovered falls that correlated with the onset of a headache for which the patient was being seen. The patient had totally forgotten about this fall. In addition, the physician’s dashboard showed other potentially related conditions including changes in sleeping patterns and activity following this episode including an episode of atrial fibrillation (Figure 5).

CONCLUSION AND DISCUSSION

Family physicians experience a wide scope of training that enables them to see and treat most conditions patients present. Concussions represent a small fraction of these visits, but concussion sequelae may be more frequent than realized. We family physicians are life-long learners and well-trained to locate and learn from the scientific literature. What we are not trained to do is extract information from our EHRs and haven’t embraced using social media “big data” to enhance our ability to answer questions our patients may have. We are even less aware of and had not been trained to utilize an ever-expanding source of information derived from apps, trackers, other wearables, and even data from the patients’ beds. The ability to do so is in the hands of patients in the Apple ecosystem but will certainly advance to all platforms and may wind up being one of the more important resources available to us. In addition to paying very close attention to patients during our exams, it is also important that we pay attention to the types of devices a patient is wearing and using. They may be a potent tool in our diagnostic armament in the near future.

MO-AFP.ORG 27

PEDIATRIC MIGRAINE: Little Brains,

BIG PAINS H Britton Zuccarelli, MD Pediatric Neurologist Salina, KS

28

MISSOURI FAMILY PHYSICIAN January - March 2022

eadaches in children can be intimidating. The etiologies can be broadly characterized into two divisions: primary and secondary headaches, with the latter referring to those that are the result of another underlying pathophysiological process. For instance, primary headaches are associated with a sinus infection or a brain mass (some differential!), and secondary headaches refer to headaches without any obvious underlying cause aside from, say, genetics. Primary headache disorders are often hereditary, with migraines representing the most common subtype, and we, as a research community, are really still in our infancy in terms of fully understanding the genetics behind this complex neurological disorder responsible for considerable disability in our country.

While the vascular theory of migraine prevailed for many years in terms of the favored pathophysiological mechanism of brain dysfunction, the cortical spreading depression theory of migraine has gained popularity since its initial description in the 1940s1. This phenomenon helps explain the transient focal neurological symptoms experienced by some migraineurs and the clinical response of some patients to antiepileptic prophylactic medications. But how do we, as clinicians, elicit a good enough history from our youngest of patients to settle on this diagnosis whilst fighting the urge to order neuroimaging? And how do we get over our distress of using potentially dangerous medications in such little patients?

The discomfort abates with experience. The incidence of primary headache disorders in children and adolescents in this country pretty well matches age

until adolescence. For example, approximately 5% of 5-year-olds, 10% of 10-year-olds, and 15% of teenagers and adults meet diagnostic criteria for common migraine.2 Unlike these children with an unremarkable neurological examination, the majority of children with brain tumors presenting with headache will harbor five or more abnormalities on examination, and less than 1% of them will present with headache alone.3 When should we be concerned? Neuroimaging should be considered in children with headache onset prior to age 3, in those less than six years of age reporting an exclusively occipital location of headache, in those with reported neurological symptoms, and certainly in response to a focally abnormal neurological examination.4 Otherwise, with a stable headache pattern in the setting of a normal neurological examination and reassuring neurodevelopmental history, no neuroimaging, laboratory investigations, or more invasive tests like spinal fluid analysis are indicated.

C Parental reassurance is paramount, as is counseling regarding M proper headache hygiene, including ensuring adequate hydration and sleep, appropriate nutrition, engagement in Y aerobic exercise, and minimizing stressors. Beyond these conservative measures, there is an ever-growing body CM of evidence to support the use of various supplements, nutraceuticals, and pharmaceutical products in the preventionMY of pediatric migraines.

CY Magnesium oxide or gluconate are the most common go-to options for children for primary headache prophylaxis. DosingCMY is generally 200-250 mg daily for smaller children and 400-500K mg daily for adolescents. Side effects include softening of the stool, so there’s little risk in getting this started in anticipation of referral to a specialist. In addition, there is some research demonstrating efficacy of this supplement in ameliorating the symptoms of common migraine comorbidities, including attention deficit-hyperactivity symptoms, anxiety, and tics.

Prescription preventative options include many of the same compounds offered to adult migraine patients, including the

tricyclic antidepressants, antiepileptics, and beta-blockers, but some other medications, like cyproheptadine and tizanidine, are frequently employed in the pediatric population as well.

Agent selection depends largely on its formulation in regards to whether or not the child will reliably and consistently swallow the medication, side effects, and payer coverage issues. The treatments generally reserved for pharmacologically-refractory adults, including botulinum toxin injections and the calcitonin gene-related peptide (CGRP) antagonists, while not FDAapproved in children, are considered in appropriate clinical circumstances.

As with adults, abortive therapies in children should be taken at the onset of headache and limited in their use to no more frequently than 2-3 times per week so as to avoid medication overuse or rebound headache. The most commonly used agents include a weight-appropriate dose of ibuprofen or acetaminophen, with or without diphenhydramine, and, oftentimes, an antiemetic. Triptans can be safely used in children.

While it is certainly important to design an abortive and preventative plan unique to each patient, the universal prescription is for focusing on function rather than disability.

Rather than using pain scales, I encourage patients to characterize their headache burden in terms of which activities they can enjoy despite the pain and from which they have to abstain secondary to headache and/or other associated symptoms. Assessing the frequency, intensity, and duration of headaches andSomly_MAFP_PrintAd_QtrPg_113021_HiRes_WBleed.pdf response to lifestyle and pharmacological interventions helps direct future treatment decisions.

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MO-AFP.ORG 29

Wildwood Physician Named MAFP Family Physician of the Year

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he Missouri Academy of Family Physicians (MAFP) presented David A. Miller, MD, MHA, CHCEF, FAAFP, of Wildwood, Missouri, with the 2021 Family Physician of the Year Award at the Academy’s 73nd Annual Meeting held November 12-13, 2021 at Big Cedar Lodge, Ridgedale, Missouri. Dr. Miller was chosen as the award recipient by a committee of family physicians from nominations made by patients, community members, and fellow physicians.

Dr. Miller has been active in the Academy throughout his career as a family physician. He graduated from the University of MissouriColumbia School of Medicine and completed a family medicine residency program at St. John’s Mercy Medical Center (now Mercy) in St. Louis, Missouri. He holds a Health Administration degree, completed a Community Health Center Executive Fellowship and is a Fellow of the American Academy of Family Physicians. This year’s family physician of the year has continuously practiced medicine in the greater St. Louis area for almost thirty years.

His focus is not only the health of his patients, but also that of his community. He is an exemplary leader through his service on the St. Louis Academy of Family Physicians, past MAFP and Foundation board member, and on the board of governors of the University of Missouri-Columbia Medical Alumni Association. In 2020, he was recognized by the St. Louis Academy of Family Physicians with the Greater St. Louis Community Health award.

His volunteer service of medical and managerial expertise has benefited groups such as a local free clinic, the Missouri Association of Free and Charitable Clinics, Missouri State Medical Reserve Corps, the Missouri Disaster Response System, Inc., the Eureka Missouri 30

MISSOURI FAMILY PHYSICIAN January - March 2022

Community Emergency Response Team, the St. Louis County Local Emergency Planning Committee, and Civil Air Patrol.

Dr. Miller currently serves as the assistant medical director and urgent care clinical director at Affinia Healthcare, a federally qualified health center serving the uninsured and underinsured populations of St. Louis City for more than 100 years.

2021 FAMILY PHYSICIAN OF THE YEAR SPEECH DAVID A. MILLER, MD, MHA, CHCEF, FAAFP

I am a traditional family physician. I am a non-traditional family physician. I have experienced, and enjoyed, the best of both of these worlds. And our training – my training, YOUR training – allows us the opportunity to do both and prepares us well for the many different ways we can serve our patients and communities.

Coming out of a very busy family medicine residency program at Mercy in St. Louis, I was looking for something … different. I joined a pain clinic and immersed myself in the world of chronic pain management learning a new discipline. But I missed the longitudinal care of patients and their families – interacting positively to influence the health of generations. I joined an urgent care network specifically to develop a continuity care clinic (that marriage of urgent care and primary care you see everywhere now); eventually buying my practice and working as a suburban family doc in St. Louis County for two decades (including eight years in solo practice).

I have since returned to urgent care medicine and currently serve as the director of one of only a handful of urgent cares across the country associated with a federally qualified health center assisting in the care of uninsured and underinsured communities in St. Louis City.

But other “non-traditional” aspects of medicine have always pulled at me. I’ve already mentioned my pivot to pain management right out of residency. I am very proud to note my ongoing eight-year commitment as a half-day-a-week volunteer physician at a local free clinic. I have served as a physician-leader in many organizations and boards – including the Missouri Academy – supporting our patients, our communities, and fellow family physicians in our state. Like many of you, I have served as a mentor and preceptor to students – from high school and medical school to doctoral pharmacy students and residents.

I have embraced a new role in disaster relief and search and rescue organizations – predominately with the Civil Air Patrol. U.S. Air Force Auxiliary, where I serve as a medical officer and public information specialist. In these roles, I am able to give back to my community in new ways – ways beyond my original role as a primary care provider caring for the needs of individual patients and their families, but to the entire greater community and communities throughout the state.

Mine has been an interesting career, and one that is continuing to evolve. Our training allows us the opportunity to do so – our broad base of knowledge, seasoned with our years of experience, provides the skills for caring for generations of patients, their families, as well

I STAND NOW AMONG MENTORS AND FAMILY PHYSICIANS I GREATLY RESPECT

as our communities. We are public health specialists. We are family health specialists. We are family physicians.

Some of you may know that I’m a big Star Trek fan – positive future and all that. I’ve met all the major Original Series and Next Generation actors except William Shatner – had dinner with George Takei, lunch with John de Lancie, and even touched Sir Patrick Stewart (but that’s another story). Impressed upon me at a young age was Dr. McCoy’s ability to treat the entire crew – men and women, young and old – and even many different alien species – a general practitioner in space, if you will.

I had the incredibly good fortune to thank him in person, talking with actor DeForest Kelly for more than 15 minutes backstage at an event, about his influence on my career as a physician. He jokingly told his wife that I was going to give him a physical! That’s when I learned that Dr. McCoy smoked Marlboros. We talked about that.

You never know who you can influence as a family physician.

I stand now among mentors and family physicians I greatly respect. It is a humbling experience to be considered among them with this great honor. I thank them all for leading the way and helping many more of us “see the light” of family medicine.

But I want to take a moment to specifically thank and remember Jean Larson, our long-serving and former executive director who has passed on. She is the one who really convinced me to pursue family medicine. As a third-year medical student, a friend and I went to an FMIG meeting (mainly to eat the free pizza), but I wound up staying a good hour after the event had ended talking with Jean. I am here before you today mainly because of that exceptional person.

Thank you for this award. You honor not only me, but those who chose challenging non-traditional family medicine careers beyond our broad base of being outstanding primary care providers.

Thank you for this honor.

AAFP Congress of Delegates, Part 1

T

he 2021 Congress of Delegates (COD) transitioned to a true hybrid meeting this year due to the COVID-19 pandemic. A decision was made months before the start of the Congress to split the COD. Although an in-person session was scheduled for February in Kansas City, that session was canceled due to COVID concerns. Your Missouri delegation consisting of Keith Ratcliff, MD, Washington; Kate Lichtenberg, DO, Kirkwood; Peter Koopman, MD, Columbia, and Sarah Cole, DO, St. Louis met in person with appropriate COVID precautions to discuss and consider the candidates for AAFP office. Alan Schwartzstein, MD, gave a farewell speech as this was his last Congress as Speaker.

Missouri AFP’s Board Chair, John Paulson, DO, provided the virtual invocation to start this Congress. Elizabeth Vasel, OMS2, at Kansas City University, shared her vocal talent and sang the National Anthem following the invocation.

Sterling Ransone, Jr., MD, (Virginia) was installed as AAFP’s 74th President. AAFP was fortunate to have five candidates for the four vacant board of directors’ positions. Each candidate has unique backgrounds and perspectives that they brought to

the board, but they all agreed family physicians are the leaders in health care and can make change to the healthcare system.

Following the election, the new leadership was announced: President Elect: Tochi Iroku-Malize, MD, MPH, MBA, New York Speaker of the Congress: Russell Kohl, MD, Kansas Vice Speaker: Daron Gersch, MD, Minnesota Directors: Gail Guerrero-Tucker, MD, MPH, Arizona; Teresa Lovins, MD, Indiana; Sarah Nosal, MD, New York; Karen Smith, MD, North Carolina.

New Physician: Samuel Mathis, MD, Texas Resident: Amanda Stisher, MD, Alabama Student: Amy Hoffman, Pennsylvania Congratulations to our new AAFP leaders and board of directors!

Look for Congress of Delegates, Part 2 in the April – June issue which will include a review of the resolutions discussed during February’s meeting.

MO-AFP.ORG 31

2022 Legislative Session Expectations and Issues

T

Randy Scherr MAFP Governmental Consultant

Brian Bernskoetter MAFP Governmental Consultant

32

MISSOURI FAMILY PHYSICIAN January - March 2022

he 2022 Legislative Session has all the right elements for the most contentious session in recent memory. This is in part because of a spillover effect from last session and the 2021 special session. The special session left many legislators unhappy not only with the way it turned out, but also the remarkable number of other factors and policy measures the General Assembly will face when they return in January.

While this list isn’t exhaustive, it does paint a picture of some of the bigger issues that will occupy much of the time and attention of legislators when they begin session in January.

Mid-Term Elections – There is an unprecedented number of legislators who are running for another or higher office. This huge reshuffling is largely a byproduct of U.S. Senator Roy Blunt not seeking reelection and the domino effect of his decision. With many legislators trying to score political points against a rival candidate for higher office, it makes the process more fraught than it already is ordinarily.

Congressional and State Legislature Redistricting – This should have been completed last session, but because of the delays in obtaining census data, it is now required to be done during this session. These delays mean you will have candidates filing for office in February without knowing the impact of the redistricting and where they live; and where they should, or should have, filed.

Medicaid Expansion – The General Assembly didn’t fund this Constitutional Amendment last session, but court rulings mean they have to fund it in some way this session. It will not be any easier for a majority of legislators who have routinely rejected efforts to expend resources to cover this population, even with the record monetary amounts on the state’s balance sheet.

Vaccine Mandates – Missouri’s General Assembly will certainly follow the lead of other conservative states to put in place laws to push back against the federal government’s COVID-19 vaccine mandates. The bigger concern is how the legislature will respond to calls coming from the same corners to make it easier for parents to opt their children out of routine vaccinations.

Critical Race Theory – There will be a concentrated effort to craft legislation that would seemingly ban CRT from being taught in schools.

Initiative Petition (IP) and Election Reforms – We could see a host of election and IP reforms proposed which draw a great deal of scrutiny from all corners of the political spectrum. Many legislators are greatly concerned about the proliferation of citizen-led initiative petition reforms that usurp the authority of the General Assembly.

Abortion – Missouri will very likely follow the lead of Texas and Mississippi to further restrict abortions.

As you can see, there will be a lot of issues that the General Assembly will have to wade through during next session. In terms of issues more specific to family physicians, we are watching a number of topics.

Healthcare Workforce Preceptor Program – This is the MAFP’s legislation to create a tax credit program to incentivize physicians and physician assistants (PA) to precept medical students and PAs. This session we will have a House and Senate sponsor and are hoping to build off our incremental success last session to get this across the finish line.

APRN Scope Expansion – There will be a number of APRN bills to expand their scope of work or allow for independent practice again this session.

Prior Authorization – Texas passed a law this year to allow medical providers who have a

demonstrated track record of ordering procedures that fall within the guidelines of insurance plans to forgo some elements of the prior authorization process for their patients.

Assistant Physician Reforms – We will continue to work with legislators to rein in the scale of our Assistant Physician program.

During the course of the session, we will provide weekly updates on the happenings in the Capitol to offer greater insight on specific legislative proposals and progress on bills of interest to our members.

You will receive these emails from office@mo-afp.org. Be sure to add this address to your safe senders in your spam filters. You can always access the current year’s legislative reports on the Members Only page of the website.

And the Survey Says…

The MAFP Advocacy Commission surveys our members on an annual basis to ensure we are representing the legislative and regulatory interests and positions of Missouri’s family physicians. This year’s survey was open for 3 months, but garnered responses from only 5% of our members . It is extremely important for you to complete this survey to ensure your voice is heard at the state capitol, in governmental offices, and on other national healthcare issues. Here is a quick summary of key issues in this year’s survey: Overall, respondents to the survey are active in advocacy efforts at the local, state, and national stages. This is accomplished through attending candidate town halls or rallies, placed political yard signs in their yards, meeting with candidates, and serving as a key contact for both AAFP and MAFP. A primary legislative initiative of the Missouri Academy is the preceptor workforce program since almost 63% of the respondent’s precept students, and over 92% of the respondents support this initiative. We are addressing an issue that is important to our members.

A recurring legislative issue is scope of practice for our mid-level team members. They are important to providing quality healthcare to our patients, but 94% of the respondents do not support independent practice and 85% do not want to increase the number of mid-level providers a physician can collaborate with (currently, 6 with any combination of NP/PA/AP.) Interestingly though, 85% of the respondents utilize nurse practitioners, 44% physician assistants, and 4% assistant physicians in their practice. The respondents are looking for common ground (63%) on scope of practice expansion.

The respondents do agree that assistant physicians should graduate from a Missouri medical school or graduate from an AAMC or COCA accredited medical school. The assistant physician license should be for a limited time period, but 38% agree that an assistant physician should not be able to practice without residency and 86% that assistant physicians should not have a pathway to full licensure.

The trends related to legalized recreational marijuana have not varied much since we began asking this question in 2017 where 67% oppose and 33% support it. However, those respondents also are inching their way toward supporting medical marijuana with a prescription or certification. Ultimately, though, most (91%) do not plan to certify patients to use medical marijuana.

The scales are about equal on the dispensing of over-the-counter contraceptives with 48% supporting some contraceptives to be available over the counter. Respondents do not support (82%) expanding the scope of pharmacists by allowing them to prescribe self-administered oral contraceptives.

An important topic that will be addressed during this year’s legislative session is immunizations. Very few (10%) respondents do not provide any immunizations in their clinics. Of those that do provide immunizations, the most common vaccine is influenza (98%) followed

by Tdap (95%), and HPV Female and Pneumococcal Conjugate both at 87%. As expected, most respondents refer their patients to the county health department (96%) or pharmacy (86%) for immunizations.

Respondents are experiencing patient reluctance which hasn’t changed

significantly since we began asking in 2019.

The COVID-19 vaccine was offered at 60% of the respondents’ clinics, and 61% of the respondents support an immunization passport.

Although COVID-19 had no or little financial impact on the practice of 72% of the respondents, there were 28% who were under significant or extreme financial impact, compared to 2020 at 38% and 62%, respectively. It seems that practices are adapting to treating patients through the COVID-19 pandemic. However, at a time when there is a shortage of family physicians and clinics, we need to support our members who are in need of financial assistance to continue their practice. 37% of the respondents applied for and received the federal government’s Paycheck Protection Program (PPP) funding; but many members did not pursue governmental assistance through the PPP, Medicare Accelerated and Advanced Payment Program, or the Economic Injury Disaster Assistance Loan Program. With clinics offering telehealth, 51% did not see a change in patient volume last year; however, 49% did see more than 20% reduction in patient volume with telehealth. Interestingly, 21% of the respondents currently do not offer telehealth services and most respondents (59%) provide 20% or less of their patient visits via telehealth. In response to the financial strains on clinics, 42% of the respondents did not make any changes, while 36% layed off or furloughed staff. 7% of the practices were temporarily closed and 16% are considering closing their practice permanently.

The primary areas of assistance needed by the respondents are helping patients access mental health resources at 54% compared to 2020 at 42%. Following this important need, the other priority areas are patient technical ability to use telehealth is 44%, which is lower than last year’s 62%, mental health/physician well being at 40% which is higher than last year’s 21%. Both internet access for patients and helping patients access resources were at 35%, compared to last year at 58% and 38%, respectively.

The demographics of the respondents are that most work in a hospital outpatient setting and in a rural health center at 45%.

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MO-AFP.ORG 33

(Left to right) Board Chair, John Paulson, DO, PhD, FAAFP; President, John Burroughs, MD; President Elect, Kara Mayes, MD, FAAFP; Secretary/Treasurer, Lisa Mayes, DO

Missouri Academy Installs New Officers

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he Missouri Academy of Family Physicians (MAFP) installed new officers during the Awards and Installation Luncheon in conjunction with MAFP’s 73rd Annual Meeting at Big Cedar Lodge, Ridgedale, Missouri, on November 13, 2021.

Serving as President last year, John Paulson, DO, PhD, FAAFP, of Joplin, Missouri, subsequently became Board Chair of the family medicine group. Other officers include President, John Burroughs, MD; President Elect Kara Mayes, MD, FAAFP, St. Louis; Vice President, Afsheen Patel, MD, Lee’s Summit; and Lisa Mayes, DO, Macon, was re-elected to a three-year term as Secretary/ Treasurer.

at Wake Forest University, and residency training at the University of Utah. He is board certified by the American Board of Family Medicine. Dr. Burroughs has 4 children.

BOARD CHAIR

VICE PRESIDENT

John Paulson, DO, PhD, FAAFP, of Joplin, Missouri, was installed as Board Chair of the Missouri Academy of Family Physicians (MAFP) during the Awards and Installation Luncheon. Paulson is the Department Chair of Primary Care at Kansas City University, Joplin Campus. He is board certified in family medicine and a Fellow of the American Academy of Family Physicians. He graduated from Oklahoma State University Center of Health Sciences and completed his residency at Cox Family Medicine Residency in Springfield, MO. Dr. Paulson is married to Crissy and they have one daughter.

PRESIDENT

John Burroughs, MD, of Liberty, Missouri, was installed as President of the Missouri Academy of Family Physicians (MAFP).

Dr. Burroughs is the medical director for Crossroads Hospice and Palliative Care. He precepts medical students from the UMKC School of Medicine as well as numerous nursing students. A certified yoga instructor, he provides yoga and mindfulness classes to his patients as well as the community. Dr. Burroughs received his undergraduate education at Duke University, a medical degree 34

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PRESIDENT ELECT

Kara Mayes, MD, FAAFP, of St. Louis, was installed as President Elect of the Missouri Academy of Family Physicians (MAFP). Dr. Mayes practices at the Mercy Clinics Weight and Wellness in Ballwin, Missouri. She completed medical school at Saint Louis University and residency at the Mercy Hospital Saint Louis Family Medicine Residency program. She is board certified in family medicine. Dr. Mayes is married and has 2 children.

Afsheen Patel, MD, of Lee’s Summit, was installed as Vice President of the Missouri Academy of Family Physicians (MAFP).

Dr. Patel practices at the St. Luke’s Primary Care Clinic in Lee’s Summit with a special interest in women’s health care, sports medicine, geriatric care, and primary and preventative care. She completed her medical school training at the Royal College of Surgeons United Kingdom, and residency at the University of Missouri Columbia Family Medicine Residency program. She is board certified by the American Board of Family Medicine.

SECRETARY/TREASURER

Lisa Mayes, DO, of Macon, Missouri, was re-elected to serve as Secretary/Treasurer of the Missouri Academy of Family Physicians (MAFP) for a 3-year term. Dr. Mayes is employed by the Samaritan Hospital in Macon, Missouri and has been practicing for 13 years.

She is board certified in family medicine. She graduated from AT Still University in Kirksville and completed her residency at Northeast Regional Medical Center in Kirksville, Missouri. Dr. Mayes has three daughters.

MAFP President John Burroughs, MD 2021 Installation Remarks One of the wonderful benefits of being involved in this organization is developing professional and personal relationships with good people like you. I would like to thank those who have served in our executive committee during my 6 years on the Academy’s Board and over the past 2 years in the Executive Committee. You have shown wonderful leadership and generosity with your time outside of your busy practice lives to help further our profession throughout Missouri. Special thanks to Sarah Cole, Jamie Ulbrich, and John Paulsen for being such excellent role models to follow.

And I cannot give enough thanks and gratitude to our Executive Director, Kathy Pabst, for her leadership, guidance, and patience in running our Academy’s daily activities. You have been such a blessing to all of us on the Board in shepherding us not only through the recent challenges of the Covid pandemic but in giving us the framework to effectively administrate and self-advocate (things that we family physicians often do not excel in doing). She has also led us through a complete re-organization of our office staff, and we could not be more impressed by the energy and professional acumen that Bill Plank (our assistant executive director) and Brittany Bussey (our strategic communications and public relations coordinator) have shown from day 1 in pushing our reach and effectiveness past where we were previously able. Thank you.

The call we hear every year is the one you will hear again this weekend.

Our profession keeps changing, and we need your help. Our Academy is guided in our efforts by strategic planning sessions every 3-5 years that are used to see how well we have met our previous goals followed by the question of: Do these goals still fit our current needs in Missouri? We are preparing for out next session this summer. Our 3 areas of emphasis from the 2018 meeting were Public Awareness, Advocacy, and Improving our Pipeline of new Missouri Family Physicians. In short time, we intensified our efforts on the latter two. These turn out to work in hand in hand. How do we get medical students excited about Family Practice in environments that revolve around specialty practices? How do we encourage more students to train in Family Practice IN MISSOURI (in hopes of keeping them in Missouri to start their careers)? When students have come to my practice in the past few years, they have been surprised by the scope of practice of a family physician. It certainly helps to improve the practices and lives of our working family physicians. We want to improve the quality and profitability for Missouri FP’s while maintaining (or preferably improving) their work-home balance. That’s where Advocacy can help.

Through advocacy in Jefferson City and Washington, DC there has been enthusiasm to increase the number of residency spots in primary care, especially in rural areas. We are VERY close to reaching approval of Preceptor Tax Credits in Missouri for those physicians who bring students and residents to their office for training. Thank you to those who are precepting because we need you to share what family physicians do. Those are wonderful developments. Thank you, Keith Ratcliff and Peter Koopman as well as our lobbyists, for spearheading those efforts over the past few years.

We have also been working diligently to encourage the state of Missouri to increase investment of health care spending into primary care. During our last Strategic Planning session in 2018, we learned of research done in several states about the effects on quality and cost of health care when there is increased investment in primary care. These studies have shown consistently-improved patient outcomes accompanied by decreased health care costs, less ER visits, and fewer hospitalizations.

The US spends 5-7% of its total health care spending on primary care (despite 48% of all office visits being primary care visits and PCP’s influencing 90% of health care costs through referrals, tests, procedures, and hospitalizations). Medicare spending in primary care? 2-4%. Durable medical equipment spending? 3%. Home health? 3%. Pharmaceuticals?

14%.

7 states have legislation to increase primary care investment (or at least study its feasibility). In the US, we spend far less on primary care than other developed countries. Other developed countries spend 10-15% on primary

care. Rhode Island had passed legislation (driven by the insurance industry!) in increase primary care investment to 12% by 2024. In data from 20082014, Rhode Island saw an increase of primary care expenditure by $27 million. Health care expenditures over that same period dropped by $115 million. Similar findings were shown in Oregon. Missouri spends 4.6% on primary care. We were energized and optimistic as we descended on Jefferson City in 2019 and 2020. Slam dunk, right? So far legislation just to investigate options in Missouri have failed to leave committee.

We need your help. We need a louder voice in Jefferson City to encourage change. To accomplish this, we need more voices. Come join us for FP Advocacy Day in Jefferson City in February. It is an exciting and educational experience. Get to know your state representative and state senator. They might be your neighbor or your patient. They value (and need) our expertise and input. Complete the surveys when we send them for your input – our positions are based on your feedback. Contribute to the MAFP PAC. Our lobbyists are fabulous, but their resources are meager.

Please help them advocate for our profession and our patients. Help us to better communicate with you. The settings in which we practice, and therefore our needs and concerns, vary tremendously. We want to hear from you so that we can work for you.

Thank you all for attending this annual business meeting and supporting our academy through your attendance at this conference. Thank you to our exhibitors, including Crossroads Hospice and Palliative Care for sponsoring this luncheon. I have been so fortunate to be associated with this wonderful company for 12 years. I started my time with the Board in 2015 with a call from a colleague and friend asking if I would consider replacing the Board position that she had to leave. At first, I said there is NO WAY that I had the time to commit to that. I called her back 10 minutes to later to tell her that I had reconsidered. I am so glad that I did. There are so many ways to affect improvement in the health of patients and communities. I hope that you will consider lending your voice to this Academy as a way to help yours.

Have a fantastic time for the rest of the conference and safe travels home.

MAFP Welcomes New MDHSS Leader

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he MAFP leadership team met with newly appointed director of the Missouri Department of Health and Senior Services (MDHSS), Don Kauerauf. We welcome his service to Missourians and look forward to working with him to improve the health outcomes of our patients.

Jamie Ulbrich, MD, MAFP Past President, John Paulson, DO, MAFP Board Chair, Keith Ratcliff, MD, Advocacy Commission Co-chair, along with the MAFP team, Randy Scherr, Brian Bernskoetter, and Kathy Pabst, met with Mr. Kauerauf in October – about 6 weeks after he joined the Show Me State.

We took this opportunity to share with Don our interest in working with him and the MDHSS on issues of mutual concern. These include the health care workforce and graduate medical education, rural practice issues, scope of practice, and graduate medical education.

Addressing these issues will help us focus on what keeps him up at night, Missouri’s atrocious health outcomes, including maternal health.

Resolutions to these issues is not only funding, but also education.

We need to work to educate Missourians about how proper health care can improve their lives and environments. Chronic health diseases are underfunded and working with our patients to improve their management of these diseases with ultimately reduce health care expenses.

Our next steps are to work with Don and other health care organizations to go down a parallel path to work together to improve the health outcomes for our patients.

MO-AFP.ORG 35

Heafner Named MAFP Outstanding Resident of the Year

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he Missouri Academy of Family Physicians (MAFP) presented John Heafner, MD, MPH, of St. Louis, Missouri, with the 2021 Outstanding Resident of the Year Award at the Academy’s 73rd Annual Meeting held November 12-13, 2021 at Big Cedar Lodge, Ridgedale, Missouri. Dr. Heafner was chosen as the award recipient by a committee of family physicians from nominations made by Missouri family medicine residency programs.

The MAFP Outstanding Resident of the Year award is presented to a graduating Missouri resident who exhibits exemplary patient care, demonstrates leadership, displays a commitment to the community, contributes to scholarly activity and is dedicated to the specialty of Family Medicine. The recipient of this award, Dr. John Heafner, has served on the board of the Missouri Academy of Family Physicians and the American Academy of Family Physicians. Dr. John Heafner completed medical school and residency at Saint Louis University, and is now employed with Family Care Health Center in St. Louis.

Tobin Receives MAFP Distinguished Service Award

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he Missouri Academy of Family Physicians (MAFP) presented Marla Tobin, MD, FAAFP, of Warrensburg, Missouri, with the 2021 Distinguished Service Award at the Academy’s 73nd Annual Meeting held November 12-13, 2021 at Big Cedar Lodge, Ridgedale, Missouri. Dr. Tobin was chosen as the award recipient by a committee of family physicians from nominations made by patients, community members, and fellow physicians.

The Distinguished Service Award recognizes members, nonmembers, and entities for long-time dedication to advancing, contributing, and supporting to the MAFP and the specialty of family medicine. This is the first Distinguished Service award to be presented by the Academy. Dr. Marla Tobin from Warrensburg has shown long term dedication to MAFP and the American Academy of Family Physicians by starting her membership in her first week of medical school in 1976 and continuing this dedication for her entire career. This dedication continued for the next forty-five 36

MISSOURI FAMILY PHYSICIAN January - March 2022

years through various career and leadership roles including many media presentations promoting Family Medicine.

Dr. Tobin spent 20 years in the AAFP Congress of Delegates and working on national committees as well as serving in leadership roles in Missouri including being President of the MAFP. She delivered over 1,300 babies, starting and managing 2 busy clinics, doing house calls, nursing home care, hospital care, surgeries, and sideline medical care for local sports teams. She also was a Medical Director for 2 national health insurance companies advocating for Family Physicians. Throughout her career she has always taught, coached, and mentored many healthcare professionals and new physicians encouraging them to enter careers in healthcare and specifically Family Medicine.

Dr. Tobin earned her undergraduate degree in biology and her medical degree from the University of Missouri Columbia.

She completed her family medicine residency at Duke University, in Durham, North Carolina.

MO-AFP.ORG 37

MEMBERS IN THE NEWS

New Family Medicine Program in Joplin, MO

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ansas City University and Freeman Health System in Joplin, MO, are pleased to announce a new family medicine residency program located in Joplin, which has received accreditation and is now receiving applications for their inaugural class starting in July 2022.

Unique Aspects of Freeman Family Medicine Program: • Strong community focus: This program reflects the deep commitment and collaboration of the community in improving the health and wellbeing of its people. Most rotations will be hosted at Freeman Health System, and the residents’ continuity clinic will be located at Access Family Care, a federally qualified

health center which provides comprehensive health care focused on the underserved in the Four States area.

• Mental health training: One of the clear needs of the region is a primary care workforce well-equipped to provide mental health care. Each year, residents will have a rotation focusing on different aspects of behavioral health care, including a month of addiction medicine. Residents will be prepared to meet this need with excellence.

For more information, visit https://www.freemanhealth. com/graduate-medical-education.

Missouri Rural Health Day Celebration

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Pictured: John Paulson, DO, PhD, FAAFP (MAFP Board Chair), Kristine Gustafson (Clinic Fund Development Coordinator & Licensed Professional Counselor), and Stephanie Brady (Clinic Executive Director) 38

MISSOURI FAMILY PHYSICIAN January - March 2022

he Community Clinic of Southwest Missouri received 1 of 5 Rural Health Champion Awards in Jefferson City at Missouri Rural Health Day on November 18, 2021.

Since the beginning of the pandemic, the clinic has expanded current services and supported the vaccine effort by vaccinating over 3,000 people and providing outreach clinics and services throughout southwest Missouri.

In addition, Misty Todd, MD, Sedalia, co-presented with Shannon Luke, MD, a PGY1-Pediatrics resident at University of Missouri Columbia, a session during this event. Dr. Todd shared her experience as a new physician in a rural community providing obstetric services to her patients.

DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review.

We love to hear from our members!

MAFP Members Participate in AAFP’s Leading Physician Well-being Program

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manda Shipp, MD recently completed a 10-month long certificate program from the American Academy of Family Physicians (AAFP) called “Leading Physician Well-being” (LPW). Dr. Shipp was one of 120 physicians selected from a national pool to participate in the inaugural year of this program, which was created to provide leadership development, training in physician well-being advocacy, and performance improvement project skill-building. They developed a System Well-being Improvement Project (SWIP) and presented this to their peers in a final Project Showcase in October.

AAFP LPW Scholars completing this certificate are wellpositioned to fill leadership roles within health care systems where they can create value around physician well-being which honors the doctor-patient relationship. This leads to a more productive and engaged physician workforce and a better-served, and therefore healthier, patient population.

Amanda Shipp, MD (Versailles)

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AFP Board Chair, John Paulson, DO, PhD, FAAFP, was selected by the AAFP to participate in the 2nd cohort of the AAFP Leading Physician Wellbeing Certificate program.

This program is a 10-month series that teaches physicians to grow their knowledge and skills in three foundational areas: Physician well-being ― build expertise through education about the current state and importance of well-being, how to measure it, and best practices to achieve it, and develop a plan to raise awareness of its importance in your practice and organization.

Leadership development ― learn how to lead through wielding influence, implement change management and performance improvement (PI) activities, and communicate with medical colleagues and others, and develop a change management plan to guide your organization’s work to improve physician well-being.

Performance improvement ― gain hands-on experience by developing and implementing a PI-CME project in your practice or organization that’s expected to wrap up one year after the program’s educational experience concludes.

Learn more about the program at https://www.aafp.org/familyphysician/practice-and-career/managing-your-career/leading-physicianwell-being.html.

John Paulson, DO (Joplin) MO-AFP.ORG 39

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ADVOCACY DAY FEB. 28 - MARCH 1, 2022

JOIN US AT CAPITOL PLAZA HOTEL & THE MISSOURI STATE CAPITOL, JEFFERSON CITY, MO

MONDAY, FEBRUARY 28 6:30 pm – 8:30 pm Legislative Briefing of Key Issues and Dinner, Capitol Plaza Hotel TUESDAY, MARCH 1 8:00 am – 1:00 pm Legislative Briefing and Breakfast, Capitol Plaza Hotel Visit Legislators’ Offices (Appointments to be scheduled for you by MAFP staff) (Lunch at hotel) 1:30 – 4:00 pm Board of Directors Meeting

REGISTER ONLINE: WWW.MO-AFP.ORG/ADVOCACY/ADVOCACY-DAY/ CAN’T ATTEND? WE’VE GOT YOU COVERED!

We will be offering a live stream of Monday evening’s detailed legislative briefing through Zoom, but you will still need to register so we can plan accordingly.

AND…we will have an opportunity for you to contact your legislators through a Speak Out portal. We will craft a message for you to use, or create your own.

CALLING ALL MEDICAL SCHOOLS & RESIDENCY PROGRAMS

Send a group of students or residents to attend this important legislative meeting.

Let’s show our legislators that we are united and serious about taking care of our patients and protecting the scope of practice for family physicians. *A limited number of complimentary sleeping rooms are available through MAFP. Contact Kathy Pabst at kpabst@mo-afp.org or 573.635.0830 for more information.

YOU ARE THE VOICE OF MISSOURI FAMILY PHYSICIANS!

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