• ANDREA HOLLOWAY JOINS MAFP AS MEMBER EXPERIENCE MANAGER
• HEART FAILURE WITH PRESERVED EJECTION FRACTION: A GUIDE FOR PRIMARY CARE PHYSICIANS
• AND MORE!
“During the interviewing process, CMH is highly unique in that they really strive to provide you with the job you want. They were able to tailor my contract to provide me with opportunities to broaden my skill set, which will allow me to continue to practice both clinical and hospital medicine. They are very open-minded and administration is willing to work with you. I feel well cared for and very appreciated at CMH, which is rare in an employer! I definitely feel that I made the right choice with CMH.”
Did you go into healthcare because you wanted to help people? Us too!
Citizens Memorial is a fully-integrated healthcare system focused on providing exceptional patient care. Many organizations may say that, but CMH is different. You can practice medicine without all the red tape and drama you might find at other healthcare organizations. Plus, you’ll be surrounded by a strong support system of other physicians and patient care teams who are engaged and connected to our mission-driven culture.
Citizens Memorial Hospital is the perfect place to have a thriving medical practice and enjoy the Ozark Mountains and beautiful surrounding lakes.
You’re going to love CMH and southwest Missouri!
DONNA SHELBY
Director of Physician Recruiting donna.shelby@citizensmemorial.com p 417-328-6273 | c 417-399-4333 citizensmemorial.com
ALYSON ANKROM
Physician Recruiting alyson.ankrom@citizensmemorial.com p 417-328-6238 | c 281-773-0777 citizensmemorial.com
DISTRICT 1 DIRECTOR Arihant Jain, MD, FAAFP (Cameron)
ALTERNATE Brad Garstang, MD (Kansas City)
DISTRICT 2 DIRECTOR Kelsey Davis-Humes, DO (Memphis)
ALTERNATE Robert Schneider, DO, FAAFP (Kirksville)
DISTRICT 3 DIRECTOR Christian Verry, MD (St. Louis)
DIRECTOR Kento Sonoda, MD, FAAFP (St. Louis)
ALTERNATE Stacy Jefferson, MD (St. Louis)
DISTRICT 4 DIRECTOR Vacant
ALTERNATE Jennifer Scheer, MD, FAAFP (Gerald)
DISTRICT 5 DIRECTOR Amanda Shipp, MD (Versailles)
ALTERNATE Jared James, MD, FAAFP (Jefferson City)
DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville)
ALTERNATE Misty Todd, MD (Sedalia)
DISTRICT 7 DIRECTOR Chad Byle, MD, FAAFP (Kansas City)
DIRECTOR Jacob Shepherd, MD, FAAFP (Lees Summit)
ALTERNATE R achel Hailey, MD, FAAFP (Lees Summit)
DISTRICT 8 DIRECTOR Andi Selby, DO, FAAFP (Branson)
ALTERNATE Barbara Miller, MD, FAAFP (Buffalo)
DISTRICT 9 DIRECTOR Douglas Crase, MD (Licking)
ALTERNATE Kristina Grant, DO (Houston)
DISTRICT 10 DIRECTOR Jenny Eichhorn, MD (Jackson)
ALTERNATE Vacant
DIRECTOR AT LARGE Eric Lesh, DO (Jackson)
RESIDENT DIRECTORS
Noah Brown, MD (Mercy)
Karstan Luchini, DO, MS (UMKC) – Alternate
STUDENT DIRECTORS
Taylor LaVelle (UMC) Vacant – Alternate
AAFP DELEGATES
Peter Koopman, MD, FAAFP
Kate Lichtenberg, DO, FAAFP
Sarah Cole, DO, FAAFP (Alternate)
Jamie Ulbrich, MD, FAAFP (Alternate)
MAFP TEAM
EXECUTIVE DIRECTOR Bill Plank, CAE
MEMBER EXPERIENCE MANAGER Andrea Holloway, MA
MEMBER COMMUNICATIONS 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
Family Medicine at the Heart of Advocacy: MAFP Board Chair Leads the Way
Prioritizing Physician Well-Being: A Strategic Imperative for Healthcare Organizations
Carving Your Own Path: Subspecialty Fellowships and Tracks in Family Medicine
Heart Failure with Preserved Ejection Fraction: A Guide for Primary Care Physicians
Andrea Holloway Joins MAFP as Member Experience Manager
2025 Midwest Obesity Symposium
MAFP 2025 Advocacy Day: A Record-Breaking Event
MAFP Priority Issues and Messages
MAFP Leadership Attends Multi-State Forum
MAFP Energizes Record-Breaking HOSA Conference
Records Set in 2025 Match
in the News
September 12-13, 2025: Midwest Obesity Symposium Hermann, MO
www.mo-afp.org/midwest-obesitysymposium
More info can be found on page 15.
November 6-8, 2025: 33rd Annual Fall Conference InterContinental Kansas City at the Plaza Kansas City, MO
www.mo-afp.org/cme-events/annual-fallconference
More info can be found on back cover.
Afsheen Patel, MD Board Chair
Kansas City, MO
Family Medicine at the Heart of Advocacy: MAFP Board Chair Leads the Way
Family medicine is more than just a profession—it’s a calling, a commitment to serving individuals and communities with compassionate, whole-person care. I recently testified at the Missouri State Capitol during MAFP’s Advocacy Day. I stood before legislators, advocating for policies that support the well-being of Missourians, emphasizing the critical role of family medicine in improving health outcomes across the state.
MAFP’s Advocacy Day sees growing participation year by year. This growing participation highlights the increasing commitment of family physicians to shaping healthcare policy and ensuring that primary care remains a priority in Missouri. Advocacy Day also provides a valuable educational opportunity for students, residents, and physicians who may not have experience advocating with state senators and representatives, equipping them with the skills and confidence to engage in policy discussions.
prioritizes prevention, chronic disease management, and equitable care for all by engaging in policy discussions.
I encourage all family physicians to take an active role in advocacy. Legislation impacts the way we practice medicine and how our patients receive care. It’s vital that we, as family physicians, remain engaged, informed, and proactive.
FAMILY PHYSICIANS DO MORE THAN TREAT ILLNESSES—THEY BUILD LASTING RELATIONSHIPS WITH PATIENTS, PROVIDE PREVENTIVE CARE, AND ADDRESS THE FULL SPECTRUM OF HEALTH
CONCERNS FROM INFANCY THROUGH ADULTHOOD
My testimony underscored a fundamental truth: family physicians do more than treat illnesses—they build lasting relationships with patients, provide preventive care, and address the full spectrum of health concerns from infancy through adulthood. Family is in the very name of our specialty. We treat the entire family unit, and through that, we strengthen our communities. This sense of connection and responsibility is why advocacy efforts remain a cornerstone of MAFP’s mission.
As a physician leader, I have long championed efforts to enhance primary care, address workforce shortages, and improve access to critical services. The presence at the State Capitol was a powerful reminder that the voices of family physicians matter. Family doctors help shape a healthcare system that
Mission Statement:
MAFP invites its members to join future advocacy efforts, ensuring that the voice of family medicine continues to be heard. Whether attending Advocacy Day, connecting with local representatives, or staying informed on key issues, every effort makes a difference.
Beyond advocacy, MAFP remains committed to providing educational opportunities for family physicians. One of the most pressing health concerns today is obesity, a growing epidemic affecting millions of Missourians. To address this challenge, MAFP is hosting the Midwest Obesity Symposium, a premier event bringing together experts to discuss innovative treatments, prevention strategies, and communitybased interventions. See more details on page 15.
Additionally, MAFP’s Annual Fall Conference provides another opportunity for physicians to gather, learn, and collaborate. With a diverse range of topics covering emerging medical advancements, policy updates, and practical clinical skills, this conference is an essential event for any family physician dedicated to professional growth and improved patient care— more details to come.
The work of MAFP and the dedication of leaders serve as a powerful reminder of the impact family physicians have—in their communities and beyond. Advocacy and education go hand in hand, and as we continue to advance family medicine in Missouri, we invite all family physicians to stand with us.
Be a part of the movement. Get involved. Your voice matters.
The Missouri Academy of Family Physicians is dedicated to optimizing the health of the patients, families and communities of Missouri by supporting family physicians in providing patient care, advocacy, education and research.
LIVE OUT YOUR PASSION
417-619-3139
michelle.freeman1@coxhealth.com
• Locations include Springfield, Missouri, and surrounding communities
• Top 100 Integrated Health System
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Enjoy every season of life with your loved ones as you bring health and healing to family-friendly cities in Arkansas, Kansas, Missouri, and Oklahoma.
We invite you to explore Family Medicine opportunities with our physician-led, integrated health care system, offering both quality patient care and a focus on physician well-being. Fee for Service, Hybrid, and Senior-Focused practice models. There’s a place for you at Mercy. For more information, please contact:
Prioritizing Physician Well-Being: A Strategic Imperative for Healthcare Organizations
Julia Flax, MD, FAAFP Chief Population Health Officer, CoxHealth Network Springfield, MO
Every year, approximately 350 physicians in the U.S. die by suicide. This means we are losing nearly one doctor a day to this tragic epidemic. Physician well-being is a critical issue that impacts the entire healthcare system. With over 50% of physicians experiencing some degree of burnout, it’s clear that we must take action. While we can’t control the myriad of challenges currently faced by healthcare organizations, we can control our response. Our organization is committed to transforming the current landscape by prioritizing physician wellbeing in a structured, systematic, and evidencebased way. Our goal is to create an environment where physicians thrive, coming to work each day with a renewed sense of mission, meaning, and purpose.
In the often volatile, uncertain, complex and ambiguous landscape of healthcare, organizations
face numerous challenges, from improving the quality of care and advancing patient satisfaction to maintaining financial stability and reducing healthcare costs. Amidst these priorities, one critical factor often overlooked is physician wellbeing. Extensive evidence points to how physician burnout and well-being intersect with these domains, making it imperative for healthcare organizations to prioritize the well-being of their physicians.
Dr. Tait Shanafelt, a leading authority on physician well-being, urges healthcare organizations to embrace a multi-faceted approach, presenting five compelling arguments: the moral and ethical case, the business case, the recognition case, the regulatory case, and the tragedy case. Each of these arguments underscores the necessity of addressing physician well-being to achieve overarching organizational goals. Naturally,
the business case speaks strongly to most senior leaders. Given the economic pressures on healthcare organizations, financial investment in well-being must be justified and substantiated.
The business case is most clearly defined in relation to the costs of physician burnout and turnover. The economic costs of physician turnover are substantial, including recruitment and replacement costs, as well as lost revenue during the interval between a departure and a new hire being fully productive. Although these costs vary by specialty, the estimated cost of turnover is roughly two to three times a physician’s annual salary. Research across multiple institutions reveals a stark correlation between burnout and physician turnover: burned-out physicians exhibit a twofold increase in the likelihood of leaving their roles. Total costs to the organization will be higher, accounting for decreased patient satisfaction, increased medical errors and malpractice claims, reduced clinical quality, reduced productivity, reduced work effort, and other consequences of low morale within the workforce.
Once a summary of the existing evidence from the published literature and information is collected on local experience, it is imperative to engage organizational leadership to share this information and demonstrate the need for action. These meetings should emphasize that the primary problem of physician burnout is not related to personal resilience but rather to variables in the system and practice environment.
The Stanford Model of Professional Fulfillment provides a helpful breakdown of the various aspects of physician wellness and can be used as a framework for engaging leaders on the importance of these initiatives. This model outlines a simple construct that acknowledges the critical role of organizational culture, the practice environment, and the role of the individual in cultivating an environment that promotes professional well-being.
standards and continuously improve our efforts. We are currently in the process of our initial application for this award, which has helped us benchmark our progress against other leading health systems.
THE PRIMARY PROBLEM OF PHYSICIAN BURNOUT IS
NOT RELATED TO PERSONAL RESILIENCE BUT RATHER TO VARIABLES IN THE SYSTEM
To further enhance our physician well-being program, the Leading Physician Well-being (LPW) Program and the Stanford WellMD Medical Director Program are programs to develop physician leaders of wellbeing. The LPW program, developed by the American Academy of Family Physicians (AAFP), focuses on building leadership skills necessary for spearheading change and championing well-being within healthcare organizations. Participants gain hands-on experience in implementing performance improvement projects, which are crucial for driving sustainable change. The program provides education on the current state of physician well-being, measurement techniques, and best practices to achieve it.
In addition to the Stanford Model, our system has leveraged the AMA Joy in Medicine Health System Recognition Program as a foundational framework to build a comprehensive organizational physician well-being program. This program has provided us with evidence-informed strategies to support physician well-being, reduce burnout, and foster a culture of professional fulfillment. The Joy in Medicine program offers clear guidelines and criteria for implementing well-being initiatives. By following these guidelines, we have been able to create a structured, systematic, and evidence-based approach to physician well-being. The program emphasizes the importance of addressing various aspects of physician wellness, including organizational culture, practice environment, and individual support. This holistic approach has allowed us to develop initiatives that promote overall well-being and professional satisfaction. Applying for the Joy in Medicine recognition has motivated us to meet high
AND PRACTICE ENVIRONMENT
The Stanford WellMD Medical Director Program equips leaders with the knowledge and tools to advance well-being at the unit level, such as departments and practices. The program includes small group exercises and discussions, fostering networking and camaraderie among participants. Participants learn to apply the Stanford Model of Professional Fulfillment and other key concepts to their own health system contexts, enhancing their ability to lead well-being initiatives effectively. By utilizing these programs, physician leaders can more effectively lead the charge in promoting physician well-being as they are equipped with the skills and knowledge to implement evidence-based strategies, drive cultural transformation, and ensure the sustainability of our well-being initiatives.
In conclusion, prioritizing physician well-being is not just a moral and ethical imperative but also a strategic necessity for healthcare organizations. By addressing the systemic factors contributing to burnout and fostering a culture of well-being, organizations can improve patient care, enhance physician satisfaction, and achieve financial stability. As a famous piece of political advice, often attributed to Winston Churchill, suggests: never let a good crisis go to waste. The time to act is now, and the benefits of doing so are clear: a healthier, more resilient healthcare workforce dedicated to providing the highest quality of care.
Carving Your Own Path: Subspecialty Fellowships and Tracks in Family Medicine
Family medicine is a flexible career path. Generally, family physicians (FPs) provide a full scope of practice to meet their communities’ needs after completing their residency training. However, some FPs develop special interests and pursue subspecialty training or fellowships related to primary care. Examples of these fellowships include geriatrics, palliative care, sports medicine, obstetrics, addiction medicine, HIV, adolescent, integrative medicine, sleep medicine, informatics, faculty development, and academic medicine.1 The duration of training ranges from one to three years, depending on the sub-specialty. Fellowship training is the most intensive option for subspecialty development and ideal for those interested in educator or researcher roles.
subspecialty – others dedicate 100% of their practice to their subspecialty. This balance can be adjusted over time as personal interests, priorities, and passions evolve.
Although family medicine residencies often focus on outpatient care, family physicians are trained to practice a wide range of practice settings, including primary care clinic, student health centers, hospitals, urgent care facilities, and nursing homes. Moreover, the type of community – urban/suburb/rural or wellserved/underserved - can also influence their scope of practice and patient demographics. The key is to tailor your practice to align with your passions and ideal scope of practice.
Examples of these fellowships include:
• geriatrics
• palliative care
• sports medicine
• obstetrics
• addiction medicine
• HIV
• adolescent
• integrative medicine
• sleep medicine
• informatics
• faculty development
• academic medicine
The other common ways of receiving subspecialty care are tracks, concentrations, or elective rotations in residency. Common examples include sports medicine, obstetrics, addiction medicine, geriatrics, lifestyle medicine, hospital medicine, academic medicine, and global health. Many residency programs tailor their curricula to accommodate a variety of trainee interests. While the track/concentration training may be less intense compared with the above-mentioned fellowship training, it allows trainees to be equipped with additional expertise and skills in residency without spending extra years and potential relocation after residency training.
After completing a subspecialty training, individual physicians can determine how much of their practice is devoted to subspecialty care. A key question is whether one prefers to become a family physician with subspecialty expertise or a specialist with primary care mind-sets. Some physicians split their time - for instance, 30% primary care and 70%
Lastly, let me share my case. I completed an HIV Primary Care track in residency and subsequently pursued an Addiction Medicine fellowship training at the University of Pittsburgh Medical Center, PA. This additional training enabled me to develop subspecialties in HIV, hepatitis C, and substance use disordersareas of care especially valuable in the underserved regions where patients may have limited resources and access to specialists. Currently, I teach substance use disorders, HIV fundamentals and HIV-related topics such as preexposure prophylaxis for medical students and residents and serve as a core faculty in the Saint Louis University Addiction Medicine Fellowship program. I am honored to provide specialized care in the underserved areas and foster the future generation of physicians with the skill to care for HIV and substance use disorders in response to the community needs and inadequate physicians with the proper training in these fields.2,3 Personally, I find my dual roles as both a family physician and a specialist deeply fulfilling, and I believe this combined practice supports my own well-being.
Kento Sonoda, MD, FASAM, AAHIVS
Saint Louis University
Department of Family and Community Medicine
Noah Brown, MD
Mercy Family Medicine
Residency Program
St. Louis, MO
Charles Hill, DO
Mercy Family Medicine
Residency Program
St. Louis, MO
Jason Maddox, DO
Mercy Family Medicine
Residency Program
St. Louis, MO
Heart Failure with Preserved Ejection Fraction: A Guide for Primary Care Physicians
Heart failure is a condition that almost every primary care provider will see in their career. With the advent of guidelinedirected medical therapy, these patients are having a better quality of life for longer periods of time. Consequently, the prevalence is increasing. According to the 2024 report from the Heart Failure Society of America, “the prevalence is expected to rise to 8.7 million Americans in 2030, 10.3 million in 2040, and 11.4 million Americans by 2050”.23 Because of the increasing prevalence, it is imperative for Family Medicine physicians to be up-to-date with the most recent guidelines provided by our specialty organizations. This article will provide Family Medicine physicians with the most up-to-date data and guidelines regarding the diagnosis and management of heart failure with preserved ejection fraction based on the 2023 Expert Consensus Guidelines from the American Heart Association/American College of Cardiology.
As we begin, let’s start with a statement of definitions that will be assumed throughout the course of the article. Additionally, these definitions will contain the newest categories of heart failure.
• Heart failure (HF): as defined by the Universal Definition of Heart Failure, is
signs and/or symptoms of HF caused by structural/functional cardiac abnormalities AND at least 1 of the following: 1) elevated natriuretic peptides; or 2) objective evidence of cardiogenic pulmonary or systemic congestion. Signs and symptoms are based on Framingham HF Diagnostic Criteria, and these can be found in the table below.
• Heart failure with reduced ejection fraction (HFrEF) – clinical diagnosis of HF and left ventricular ejection fraction (LVEF) < 40%
• Heart failure with mildly reduced ejection fraction (HFmrEF) – clinical diagnosis of HF and LVEF 41% to 49%
• Heart failure with improved ejection fraction (HFimpEF) – previous LVEF < 40% and a follow-up measurement > 40%
• Heart failure with preserved ejection fraction (HFpEF) – clinical diagnosis of HF and LVEF > 50%
• HFpEF mimics – clinical diagnosis of HF and LVEF > 50% with a primary non-cardiac cause (kidney or liver disease) or an underlying cardiac cause (infiltrative cardiomyopathy, hypertrophic cardiomyopathy, valvular disease, pericardial disease, or high-output HF)
2 or more major criteria OR 1 major criterion + 2 major criteria
Major Criteria
• Orthopnea
• Jugular venous distension
• Hepatojugular reflux
• Rales
Minor Criteria
• Dyspnea on exertion
• Nocturnal cough
• Ankle edema
• S3 gallop rhythm
• Acute pulmonary edema
• Cardiomegaly
• Tachycardia - HR > 120
• Hepatomegaly
• Pleural effusion
Table 1
Epidemiology
As already mentioned, the prevalence of heart failure, in general, is increasing, and it is suggested that cases will continue to increase. Among all of the categories of heart failure, the incidence of HFpEF is rising at a more rapid pace. This is supported in three longitudinal cardiovascular health studies. First, the Framingham Study reveals that, of those patients with heart failure, HFpEF accounts for 51% of patients versus 49% with a reduced ejection fraction. HFpEF was also seen in higher proportions in women versus men (72% vs 33%)6 Similar results were seen in the Strong Heart Study, a populationbased study in American Indian communities in Arizona, Oklahoma, South Dakota, and North Dakota. In this population, the prevalence of clinical heart failure with normal LVEF (defined as LVEF > 54%) was 1.9% in North and South Dakota, 0.7% in Oklahoma, and 2.2% in Arizona. Of those with clinical heart failure, the incidence of those with normal LVEF was 52%.5 Lastly, the Cardiovascular Health Study, a multicenter longitudinal cohort study of cardiovascular disease risk in the noninstitutionalized, independent-living, community-dwelling participants at or above 65 years old, again shows similar incidence. The prevalence of clinical heart failure in this population was 8.8% and the incidence of those with preserved EF at 55%.4
Understanding HFpEF: Pathophysiology and Risk Factors
Heart failure with preserved ejection fraction results from years of chronic insult to the heart, leading to symptomatology and often cardiac remodeling that can be appreciated on echocardiogram. It is frequently described as a complex, heterogeneous clinical syndrome that is becoming increasingly prevalent. Over the past two decades, extensive research has aimed to understand the pathophysiology of HFpEF and the comorbidities that contribute to its etiology.
HFpEF is often associated with cardiac remodeling, most commonly affecting the ventricles and left atrium. However, a subset of HFpEF patients may not show any structural changes in the heart. The most prevalent form of chamber remodeling is concentric thickening of the left ventricle (LV), characterized by increased LV wall thickness with a normal or near-normal end-diastolic volume. This thickening can even be observed microscopically, with cardiomyocytes in HFpEF exhibiting increased diameter with relatively unchanged length. These micro and macro changes result in overall dysfunction during the diastolic phase of the cardiac cycle, with abnormalities noted at nearly all stages.
Aging is associated with diastolic dysfunction and the presence of this finding alone on an echocardiogram is not diagnostic or even suggestive of HFpEF. However, in HFpEF, it is thought that the cardiac
Leading Risk Factors for HFpEF
• Increasing age
• Female sex
• Systemic hypertension
• Obesity
• Sedentary lifestyle
• Myocardial ischemia
• Atrial fibrillation
• Anemia
• Chronic kidney disease
aging process is perhaps accelerated, turning a natural “dysfunction” into a problematic one.32
Obesity is considered a key risk factor for HFpEF and is even included in diagnostic scoring systems reviewed later in this article. This is thought to be related to the proinflammatory state associated with obesity, exposing cardiomyocytes to reactive oxygen species, which could contribute to the accelerated aging theory.3, 33, 34, 35
Hypertension, atrial fibrillation, anemia, myocardial ischemia, and other injurious stressors further contribute to the cumulative injury to the cardiac system that can culminate in HFpEF.
Diagnosis
Making the diagnosis of HFpEF is the initial and most challenging step in managing this condition. HFpEF can present with a multitude of non-specific symptoms and exam findings as well as varying severity. This, combined with the broad differential of other etiologies, makes HFpEF a particularly difficult diagnosis to confirm. Importantly, no single test definitively establishes the diagnosis, and it is crucial to consider mimics.
A case example can highlight the challenges of making the diagnosis:
BG is a 67-year-old female who presents to your clinic to establish care after moving to the region post-retirement. She has a past medical history of obesity, type 2 diabetes managed with metformin, hypertension well controlled on losartan and chlorthalidone, hyperlipidemia treated with atorvastatin, and a diagnosis of chronic HFpEF managed with furosemide 40 mg once daily. She reports that this HFpEF diagnosis was made years ago, and she has been taking furosemide since that time. If she misses doses of furosemide, she experiences mild ankle swelling. Otherwise, she has no other significant symptoms and is feeling well. There is no echocardiogram or BNP on file for review. You order these missing pieces of the workup and reveal a NT-proBNP was 230 pg/mL, and the echocardiogram showing an E/e’ of 13 and a PASP of 42.
Diagnosis Confirmation
In this vignette, the patient has a historical diagnosis of HFpEF that needs to be confirmed before initiating GDMT. The most straightforward approach to diagnosis is utilizing the Universal Definition of HF, as described above. If either the history or physical exam suggests the possibility of HFpEF, the next steps are to proceed with BNP and echocardiogram to obtain objective evidence. An important caveat regarding BNP in the setting of HFpEF is that a 50% reduction in cutoff values should be used in the diagnosis of HF in individuals with obesity, as suggested by the Heart Failure Association of the European Society of Cardiology.24
Diagnostic Scoring Systems
Once the echocardiogram and BNP have been obtained, the use of HFpEF diagnostic scoring can potentially aid the clinician. These scoring systems include the H2FPEF and HFA-PEFF scores.
The H2FPEF consists of six readily available components and a total score ranging from 0-9. It can be used not only as a diagnostic tool but as a prognostic one with higher scores being associated with all-cause mortality and 1-year rehospitalization rates.25 The components are of the H2FPEF are listed in Table 2.
An H2FPEF score ≥ 6 is considered diagnostic of HFpEF, with scores 2-5 classifying patients as intermediate likelihood of having HFpEF. When using the cutoffs of ≥ 6 for diagnosis, the sensitivity is 43.6% and the specificity is 82.1%; sensitivity increases to 89.5% if using a ≥2 cut-off. Unfortunately, in a patient presenting with dyspnea, a common concern in the primary care office, specificity decreases to 69.1% with a LR+ of 1.37.26
Another useful tool is the HFA-PEFF score, which is more involved and includes hemodynamic assessment. It contains major and minor
H2FPEF Calculator
Variable Age BMI
E/e’ Ratio
Hypertension
Pulmonary artery systolic pressure
Atrial Fibrillation
Result
Scoring
1 point for each decade over 40
1 point for BMI > 30
1 point for E/e’ >9
1 point for ≥2 Antihypertensive medications
1 point for PASP > 35 mmHg
1 point if present
Sum of Points
Table 2
criteria in three categories. If any major criterion is positive the category contributes 2 points, if no major but any minor the category contributes 1 point36. This tool is primarily used by cardiologists to help differentiate HFpEF from other etiologies given that it uses more specific data points.
• Functional: E/e’, e’, tricuspid regurgitation velocity, global longitudinal strain
• Morphological: left atrial volume index and parameters which reflect left ventricular hypertrophy
• Natriuretic peptides levels
A HFA-PEFF score ≥ 5 is considered diagnostic of HFpEF, while a score of 2-4 classifies patients as intermediate likelihood of having HFpEF. With the ≥ 5 cutoff, sensitivity is 70% and specificity is 90.5% with a PPV of 97.2%27 .
These scoring systems may provide some degree of aid to the primary care physician in clarifying an HFpEF diagnosis, but they should be used in conjunction with good clinical judgement. Importantly, a significant number of patients will fall into the “intermediate” categories after the application of the scoring systems, suggesting testing for other etiologies of reported symptoms to be essential. Interestingly, in a Netherlands heart failure clinic where both scoring systems were applied to patients with LVEF > 50%, they were classified differently by one versus the other scoring system 41% of the time, potentially limiting the clinical use of these scoring systems27
With all this in mind, we will tentatively apply a scoring system in our vignette using the H2FPEF system which gives a score of 6, which is highly suggestive of HFpEF. This in conjunction with clinical history indicates she is a candidate for GDMT and should be initiated on the therapies described below. In situations where the scoring systems are indeterminate and HFpEF is highly suspected, a therapeutic trial of GDMT is a reasonable first step, especially if more intensive diagnostic testing is not readily available or wanted by the patient.
In the above vignette, the patient had a historical diagnosis, which was confirmed with additional testing. However, a more common presentation is a patient with symptoms of dyspnea on exertion, exercise intolerance, and/or lower extremity edema. In these situations, mimics must be considered and ruled out through further evaluation and testing.
Case Resolution
After discussion with BG, it was decided to move forward with prescribing GDMT, as described below.
Management
As we prepare to discuss management options, let us first ask the question: what is our, as Primary Care Physicians, role in the management of HFpEF? As always, we should be able to recognize the signs and symptoms of HFpEF, initiate the diagnostic testing, and determine when cardiology referral is warranted. Additionally, with the changing definitions and terminology that are being put forth, we are perfectly situated to be able to correct the medical record where appropriate (for example, no longer considering “diastolic dysfunction” on echocardiogram without symptoms as HFpEF) and to be able to walk patients through the often confusing labels that are assigned to them and/or their medical chart. Lastly, we would like to put forward that Primary Care Physicians should also feel empowered to begin treatment. There is new data coming out regarding the treatment of HFpEF, and, now, we will dive into some of this data below.
SGLT-2 inhibitors were originally developed in the management of type 2 diabetes mellitus. In addition to benefit in this pathology, SGLT-2 inhibitors have also been shown to significantly reduce the risk of hospitalization for heart failure and cardiovascular death in patients with heart failure with reduced ejection fraction. According to the 2023 ACC/AHA Expert Consensus Decision Pathway for HFpEF, SGLT-2 inhibitors should be considered for all patients with HFpEF, regardless of ejection fraction. There are two major trials that support this recommendation: DELIVER (Dapagliflozin Evaluation to Improve the LIVEs of Patients with Preserved Ejection Fraction Heart Failure) trial and EMPERORPreserved (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction). In these trials, the primary outcome (composite of hospitalization for heart failure and cardiovascular death) was noted to be significantly reduced with their respective SGLT-2 inhibitor (DELIVER: HF 0.82 (0.73-0.92)14; EMPEROR-Preserved: HR 0.79 [0.69-0.90]15). This was mostly seen in a significant decrease in the hospitalizations for heart failure (DELIVER: HR 0.79 (0.69-0.91)14; EMPEROR-Preserved: HR 0.71 [0.600.83]15) versus cardiovascular death (DELIVER: CV death 0.88 (0.74 - 1.05); EMPEROR-Preserved: HR 0.91 [0.76-1.09]). A meta-analysis that was performed, looking at both of these trials in addition to three others (DAPA-HF, EMPEROR-Reduced, SOLOIST-WHF), and this also showed consistent reductions in both CV death (HR 0.88 [0.771.00]) and first hospitalization for HF (HR 0.74 [0.67-0.83]).16
Mineralocorticoid Receptor Antagonists (MRAs)
Per the 2023 guideline, MRAs do improve measures of diastolic function in patients with HFpEF. The TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial, when published in 2014, initially appeared to have not shown a significant reduction in its primary outcome, composite of death from cardiovascular causes, aborted cardiac arrest, or heart failure hospitalization (HR 0.89 [0.77-1.04]). However, a subsequent subgroup analysis of the TOPCAT trial did show a significant reduction in the primary outcome in the enrollees from North America (HR 0.82 [0.69-0.98]) versus no benefit found in enrollees from Russia and Georgia (HR 1.10 [0.79-1.51]), which accounted for about 49% of the total study population. In 2017, Denus et al found that, in 366 participants (206 from North America and 160 from Russia) in whom a metabolite of spironolactone, canrenone, was measured, canrenone concentrations were undetectable in a higher percentage of participants from Russia versus North America, despite all the participants reporting they were taking the assigned dose.11,12,13
With all the data that is currently available in regard to use of MRAs in HFpEF, it is recommended by the ACC/AHA to start a MRA, as “most individuals with HFpEF will still benefit from MRAs to provide balanced diuresis with sequential nephron blockade, control hypertension, and reduce HF hospitalizations”1.
Angiotensin Receptor-Neprilysin Inhibitor (ARNI)
The PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction) trial compared sacubitril/valsartan (target dose 97/103 mg twice daily) versus valsartan (target dose 160 mg daily) in patients that met three criteria: 1) LVEF > 45%, 2) elevated natriuretic peptides, and 3) structural heart disease. In this study, the primary outcome, defined as a composite of HF hospitalizations and death due to cardiovascular causes, was not significantly lower between the treatment groups (rate ratio 0.87 [0.75-1.01]). Interestingly, the data did show improved primary outcome measures in two subgroups: those with LVEF 45-57% (rate ratio 0.78 [0.64-0.95]) and in women (rate ratio 0.73 [0.59-0.90]). With this, sacubitril/valsartan does have FDA indication for “chronic heart failure” though there is more clear evidence for its use in patients with below normal ejection fraction.17
Angiotensin Receptor Blockers (ARBs)
ARBs are considered to be used when an ARNI cannot be used, whether for side effects or expense. There are two trials that we will discuss to provide evidence behind this recommendation.
First, in the CHARM-Preserved (Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity) trial, researchers looked at candesartan (target dose 32 mg daily) versus placebo. The study enrolled patients who were classified as New York Heart Association functional class II-IV and LVEF > 40%. In this, the primary outcome (composite of heart failure admission and death due to cardiovascular cause) was borderline significant (covariate-adjusted HR 0.86 [0.74-1.00]).18
Second, in the I-PRESERVE (Irbesartan in Heart Failure with Preserved Systolic Function) trial, patients meeting inclusion criteria (age > 60 years old and LVEF > 45%) were randomized to receive either irbesartan (with a target dose of 300 mg daily) versus placebo. The primary outcome, defined as a composite of death from any cause or cardiovascular hospitalization, was not significantly reduced (HR 0.95 [0.86=1.05]).19
Because of the discordant data, ideally patients would be on an ARNI. However, if unable to be on this medicine, an ARB should be considered after a risk versus benefit discussion.
Angiotensin-Converting Enzyme (ACE) Inhibitors
In the PEP-CHF (Perindopril in Elderly People with Chronic Heart Failure) trial, the efficacy of perindopril was assessed. In the enrolled patients, who were > 70 years old with a diagnosis of heart failure and a mean LVEF of 64-65%, the primary outcome, defined as composite of all-cause mortality or unplanned heart failure related hospitalization, was not shown to be significantly reduced (HR 0.92 [0.70-1.21]).21
Beta-Blockers
In the 2005 SENIORS trial, the effectiveness of beta-blockers was evaluated. This trial looked at a beta-blocker (nebivolol) versus placebo in the management of patients > 70 years old with heart failure. Of these, 752 patients had a LVEF > 35%. In these patients, nebivolol was shown to not be significant in reducing the primary outcome, which was defined as composite of all-cause mortality or cardiovascular hospital admission (HR for LVEF > 35% subgroup 0.82 [0.63-1.05]).20
GDMT for HFpEF
Women - all EFs Men - EF < 55-60% or those with fluid
Women - all EFs Men - EF < 55-60%
If qualify for ARNI but unable to take due to tolerability or cost
Empagliflozin: 10 mg daily
Dapagliflozin: 10 mg daily
Spironolactone: 50 mg daily
3
Furthermore, in 2009, data from the OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry revealed that, in patients with HFpEF, there was no significant benefit to beta-blocker initiation on cardiovascular mortality or heart failure hospitalizations (adjusted HR 0.98 [0.911.06]).10
trials on exercise, showed that exercise training improved functional
capacity (as noted by improved peak exercise oxygen uptake and six-minute walk distance) and quality of life (by the Minnesota Living with Heart Failure Questionnaire) when compared with usual care.22 When to Refer to a Specialist
As we consider management, it is also important to know when we need to reach out for specialist assistance in diagnosis and/
Andrea Holloway Joins MAFP as Member Experience Manager
The Missouri Academy of Family Physicians (MAFP) is thrilled to welcome Andrea Holloway as its new Member Experience Manager. With a deep passion for advancing healthcare and a proven track record in nonprofit leadership, substance use disorder treatment, and public health advocacy, Holloway brings invaluable experience to MAFP’s mission.
In this role, Holloway will drive membership education, growth, and support, while strengthening outreach, engagement, and content development. Through these efforts, MAFP members will gain even greater access to resources, networking opportunities, and professional development to enhance the impact of family medicine across Missouri.
In her leadership role at a nonprofit dedicated to prevention efforts for youth and adults, she played a vital part in communitybased initiatives aimed at reducing substance use and promoting mental wellness. Additionally, Holloway has worked as a substance use disorder treatment counselor, guiding individuals through recovery and support services.
Holloway has also contributed to government-led efforts addressing patient care, working to advance policies and programs that support individuals and families in need. Most recently, she has been involved in the development of acute withdrawal management services within a hospital setting, ensuring access to critical care for those struggling with substance use.
Driven by a passion for optimizing the health of patients, families, and communities across Missouri, Holloway is committed
to supporting family physicians with the resources needed to enhance patient-centered care.
“I am excited to join MAFP and look forward to engaging with our members, providing valuable content, and expanding opportunities for professional growth and collaboration,” said Holloway.
Born and raised in Jefferson City, Andrea is rooted in Missouri values and proud to serve her home state. She and her husband, Cole Holloway of Fulton, have been married for 16 years and live in Wardsville with their three active children, all of whom attend Blair Oaks School District—We are Blair Oaks!
Their oldest, Jeg (15), is a freshman who plays wide receiver, safety, and serves as a kicker for the Blair Oaks football team, as well as catcher and pitcher for the baseball team. Their daughter Adeligh (14) plays mid defender for her traveling United Capital City Soccer Team and shines as a guard and post on her 7th grade basketball team. Their youngest, Easton (12), is full of charisma and is the goalie for his soccer team, while also kicking for his 6th grade Junior Falcons tackle football team.
“As a mom of three, there’s not a whole lot of ‘spare time,’” Andrea jokes. “But when there is, it’s all about family—celebrating birthdays, camping, going to games, and cheering on nieces, nephews, and our amazing kids.”
Andrea can be contacted at aholloway@mo-afp.org.
M I D W E S T 2025 OBESITY SYMPOSIUM
September 12-13, 2025
Hermann, Missouri
About the Event
The Missouri Academy of Family Physicians is excited to announce the Midwest Obesity Symposium, September 12-13, 2025, at the Hermannhof Festhalle in Hermann, Missouri. Nestled on the Missouri River, surrounded by vineyards, and with convenient access to the Katy Trail, this obesity medicine-focused conference will balance education with relaxation.
Unlike most conferences you may have attended, this meeting does not have a hotel or room block attached, as Hermann is known for their quaint lodging choices. Attendees will be responsible for booking their own lodging.
The conference is anticipated to start with lunch on Friday and conclude on Saturday afternoon. Registration cos AAFP Members is $225 and $300 for Non-AAFP memb
To register, scan the QR code below or visit: www.mo-afp.org/midwest-obesity-symposium.
MAFP 2025 Advocacy Day: A Record-Breaking Event
The Missouri Academy of Family Physicians (MAFP) hosted its largest Advocacy Day to date on February 24-25, 2025 in Jefferson City, Missouri. Nearly 80 family physicians, residents, and students registered for the annual event. An almost 50% increase from the largest number of registrants in previous years.
This year’s event purpose was twofold. First, new advocates engaged in an informative session to learn how to advocate for themselves, their patients, and their communities in multiple settings. Second, current and future family physicians were provided tools and a platform to engage with legislators on issues impacting the specialty of Family Medicine with a focus on patient care.
Day 1: Monday, February 24, 2025
The first day focused on equipping new advocates, including medical students and residents, with foundational advocacy skills. The agenda included:
• Welcome and Introductions: Led by MAFP Executive Director, Bill Plank, CAE
• Introduction to the Missouri Legislative Process: Presented by Speaker of the House, Jon Patterson, MD.
• Do’s and Don’ts of Advocacy: Discussion on Balancing Personal Beliefs and Professionalism: Presented by Peter Koopman, MD, and Sarah Cole, DO, MAFP Advocacy Commission Co-Chairs.
• AAFP Government Relations Introduction and National Advocacy Update: Presented by Julie Harrison, Senior Manager, State Affairs & Member Advocacy and David Tully, Vice President, Government Relations, American Academy of Family Physicians
• Advocacy Workshop: Strategies on Effective Self-Advocacy: Presented by Blake I. Markus, JD, Partner at Carson & Coil, P.C.
• The Role of Organized Medicine in Your Career and How Advocacy Helps: Insights from Kathy Pabst, MBA, CAE
Following the day’s learning, the group met at the Missouri State Capitol for a functional tour led by Brian Bernskoetter, MAFP Legislative Consultant. The purpose of this tour was to introduce first-time Capitol visitors to the building to see where legislator offices, hearing rooms, house and senate chambers, and common
meeting places are located in preparation for our Tuesday visits. Attendees were given the opportunity to explore Jefferson City and have dinner on their own before meeting back at the Courtyard Marriott for a legislative briefing led by Brian Bernskoetter, Dr. Peter Koopman, and Dr. Sarah Cole. The legislative briefing was broadcast virtually for those unable to attend in person. A brief overview of some legislative tips and tricks and background on the Missouri legislature was given before we discussed current issues and MAFP positions. Attendees were invited to engage and ask questions. Day 2: Tuesday, February 25, 2025
The second day centered on direct legislative engagement: Attendees were treated to a buffet breakfast and overview of the legislative climate led by Brian Bernskoetter. Attendees were also invited to ask any last-minute questions on issues pertaining to family physicians and MAFP positions on certain bills before heading to the Capitol.
Legislative Visits: Participants met with legislators to discuss key issues, including:
• Support for Physician-Led Healthcare Teams: Emphasizing the importance of physician leadership in delivering cost-effective care.
• Reducing Administrative Complexity: Advocating for measures to decrease administrative burdens, allowing more time for patient care.
• Ensuring Access to Quality Healthcare: Supporting initiatives to expand Medicaid and insurance coverage for underserved populations.
• Safeguarding the Physician-Patient Relationship: Opposing mandates that interfere with evidence-based medical practices. The event concluded with an MAFP Board Meeting at the Courtyard Marriott, reflecting on the day’s advocacy efforts and planning future initiatives.
Although a date has not yet been finalized for the 2026 Advocacy Day, it has historically happened on the last Monday and Tuesday in February. We hope you can join us next year in Jefferson City as we continue to advocate for our profession, patients, and communities.
Advocacy Day Reflection: Reed Apostol, Student, Kansas City University
I long told myself that volunteer work – tutoring, library programs, EMS – was my community involvement. As a first-year medical student, attending MAFP Advocacy Day wasn’t on my radar until an upperclassman mentor mentioned Family Med Club needed one more person. A few hours after committing, I started to panic – Me? Speaking to politicians? – but the instant support from classmates and the MAFP organizers kept me from backing out of what turned into one of the most important things I’ll do in 2025.
The only first-year student in the room, I was nervous but quickly noticed that even at very different career stages – preclinical or clinical students, residents, and attendings – there was the sense that we were all on the same team. Questions were free flowing, and I was able to pick brains about my future role in healthcare, both as an advocate and a physician, and came away with a variety of suggestions and approaches.
During the workshops I was most surprised to learn amid explanation of processes and interdisciplinary communication techniques, that the hot seat was not nearly as hot as I expected: the questions asked in legislative hearings were often to understand basic points of practice or care, and in smaller meetings the quick,
can learn,” I thought.
A Capitol-seasoned attending came with me for the meetings arranged with my House Representative and Senator. My first attempts were as clumsy as I’d expected, but this was okay: the attending kept the conversation smooth, and I walked away from my last meeting realizing that I had concrete ideas of what I would work on for next time – because there would be a next time.
The experience gave me the chance to make connections with multiple upperclassmen at my school in the process of preparation, attendance, and post-event discussion. At the Day, I met dozens of other students, residents, and attendings from Missouri, and enjoyed being surrounded by others that have put their heart and lives into Family Medicine. I had the chance to discuss the current issues and help speak meaningfully to decision makers, giving a face to one of their local constituents.
But the punchline is this: in 2012, Kerry Washington said, “You may not be thinking about politics, but politics is thinking about you.” Regardless of whether we choose to involve ourselves, regardless of our discomfort with the process, decisions that affect us and our patients will be made. If you’re wondering if Advocacy Day will be enough to open the door for you, know that you’re thinking the same thoughts as I thought in January – and the answer is yes. Be brave. I’ll see you there.
flexible elevator pitch scaled to audience was key. “This I
PATIENTS NEED A PHYSICIAN TO LEAD THE HEALTH CARE TEAM
The physician-led team approach delivers the best and most cost-effective care to Missourians. Affiliated care providers such as nurse practitioners, physician assistants, and assistant physicians are dedicated, skilled members of the health care team but are not substitutes for physicians. The pathway to better healthcare for Missourians is physician recruitment and retention efforts.
• We oppose initiatives to provide licensure pathways that do not support evidence-based ACGME training.
• 4 out of 5 patients prefer a physician-led health care team (AMA 2018 Survey)
• A recent study from the Hattiesburg Clinic in Mississippi showed advanced practice providers (APP) increased the cost of care for patients in their clinic through increased testing, more referrals, and higher emergency department utilization.
• A 2022 National Bureau of Economic Research study found that independently practicing NPs within the US Dept. of Veterans Affairs increased the patient’s length of stay, raised the cost of emergency department care, raised the 30-day preventable hospitalizations, decreased opioid prescriptions, and increased antibiotic prescriptions.
• A new nurse practitioner receives 3-10% (500 – 1,000 hours) of the clinical training of a family physician (minimum 15,000 hours.) (Source: Primary Care Coalition)
• Mid-level providers practice primarily in the higher population geographic areas with fewer in health professional shortage areas (HPSA). The 2022 Missouri Board of Nursing Workforce reports shows that 5.3% of APRNs practice in a rural area. Data from states with independent practice for mid-level providers clearly support independent practice does not resolve the health care workforce shortage.
• A standardized curriculum from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education ensures all physicians are trained on the best practices, research, and advancements across the continuum of medical education. APRN programs are not required to maintain a standardized curriculum and most content is taught online.
• Considering the physician shortage, geographic APRN location data, and the proliferation of APRN online courses, it is imperative to increase the number of primary care physicians. This will not only meet today’s demand for physicians but will also ensure there is a qualified workforce in the future for Missourians.
• A solution to the workforce shortage should include student loan repayment for physicians and grants to physicians who work and reside in rural counties.
• Alternative healthcare education, such as Naturopathic, does not prepare practitioners to properly and accurately diagnose or provide appropriate treatment, safely or effectively prescribe medications, perform physicals, or perform surgical procedures.
• Missouri is a national leader in medical school enrollment and has taken important steps to help retain medical school graduates in Missouri residencies in recent years. We support funding of primary care residency slots to keep doctors in Missouri and applaud the investments made in Missouri’s healthcare delivery through the budget process. We ask that the current funding of $2.3 million for primary care residency positions be continued in 2026.
MAFP Priority Issues and Messages
REDUCING ADMINISTRATIVE COMPLEXITY HELPS PATIENTS
Cumbersome tasks and administrative hurdles are a leading cause of burnout among physicians. Decreasing administrative complexity will provide more time for patient care and help retain physicians. MAFP supports measures that remove administrative complexity and provide more time for patient care.
• Each prior authorization costs $4 to $11. This administrative burden costs $82,975 per physician per year and 14 hours per week. That time could be spent seeing patients.
• MAFP supports measures that simplify the licensure process for physicians while ensuring qualified physicians with adequate education and training are providing care to Missourians.
PATIENTS DESERVE ACCESS TO QUALITY HEALTH CARE
MAFP believes that all Missourians should have access to high-quality health care services regardless of social, economic, or political status, race, religion, gender, or sexual orientation.
• We support measures that increase Medicaid and insurance coverage to Missourians who lack affordable health care.
• MAFP supports immunizations to protect Missouri’s infants, children, adolescents, adults, and seniors when administered in a safe setting.
• MAFP supports local health agencies to develop public health policies and plans that could mitigate the impact of an epidemic on their communities. We support evidence-based decisions to ensure the safety and health of communities in ordinary times and in a state of emergency.
• Routine vaccines prevent and eradicate preventable diseases. These immunizations are a vital component of better public health and should be readily available at all family physician offices. Providing vaccinations to patients should not be financially detrimental to family physicians.
SAFEGUARD THE PHYSICIAN AND PATIENT RELATIONSHIP
MAFP supports evidence-based practice of medicine, the patient-physician relationship, and the delivery of safe, timely, and comprehensive care.
• Physicians should not be criminalized for health care provided to Missourians.
• Physicians have undergone the extensive training required to assess the appropriate need for treatment and to prescribe therapies as may be indicated and appropriate for the patient.
• A physician is best equipped to assess conditions in the context of the whole patient, recommend, order, and interpret diagnostic tests and imaging studies, and refer to other specialists as needed.
• MAFP does not support mandated care or specific continuing medical education for physicians.
• Family physicians provide care based on the patient’s needs, and evidence-based medicine not on political ideology. Guidelines for curriculum and accreditation for medical schools and residencies have been developed based upon clinical practices that support people and healthy communities. We oppose curriculum mandates on medical education as well as any specific continuing medical education topics for licensure.
• Physicians should be able to practice in settings that are best for them and their patients. We support measures that restrict noncompete clauses and provide physician employment mobility options.
Missouri Health Facilities Review Committee (MHFRC) Board Member Vacancies
The MHFRC is seeking applications to fill three (3) vacancies on the committee appointed by the Governor. The Committee reviews and makes decisions on proposed Certificate of Need (CON) applications and requests required for new hospitals, long-term care facilities/ hospitals, and major medical equipment. The committee also assists in CON rulemaking. Goals of the committee are to contain health costs, promote economic value, evaluate competing interests, prevent unnecessary duplications, and disseminate health-related information to affected parties.
The committee meets in person six (6) times a year, in Jefferson City, generally at the State Capitol building. In person meetings typically last between two (2) to six (6) hours. Members are expected to review CON applications and requests on the agenda prior to the meeting and become familiar with CON Statutes/Regulations. Monthly email
ballot meetings also occur. Term length is two (2) years or until replaced. Members receive reimbursement for per diem, however this is not a paid board position. Members are required to file a Personal Financial Discloure with the Missouri Ethics Commission upon appointment and annually during their term on the committee.
Interested candidates can apply through Missouri Boards & Commissions linked below by creating an account and submitting a detailed resume. A conflict of interest form may be required: https://apps1.mo.gov/boardsapp/UserPages/ Login.aspx
Information about the MHFRC and CON can be found here: https://boards.mo.gov/UserPages/Board.aspx?307
Questions about the Committee or CON can be directed to Alison Dorge, CON Program Coordinator at 573-751-6700 or alison.dorge@health.mo.gov
Submit a Resolution for the 2025 Congress of Delegates
Missouri Academy of Family Physicians members are invited to make a recommendation to the MAFP Board of Directors to consider a resolution to be submitted on behalf of our members at this year’s AAFP Congress of Delegates (COD), October 4-6, 2025 in Anaheim, CA.
The MAFP considers many issues that are important to our members. The American Academy of Family Physicians COD meets annually to develop and set policy for the AAFP and to elect its officers and the AAFP Board of Directors.
More information about submitting a resolution can be found on our website https://www.mo-afp.org/about/congress-of-delegates/.
The Maternal Health Access Project (MHAP) & Missouri Child Psychiatry Access Project (MO-CPAP) offer no-cost programs to support Missouri’s healthcare providers in caring for perinatal & pediatric patients with mental and behavioral health concerns.
Both MHAP & MO-CPAP services are available for all providers in Missouri and are offered free of charge.
MAFP Leadership Attends MultiState Forum
The 2025 Multi-State Forum was held in San Diego, California February 21-23, 2024. MAFP Board Vice President Lauren Wilfling, DO, FAAFP and Bill Plank, CAE Executive Director attended the event focused on legislative tactics and leadership development. In addition to AAFP staff involvement, state chapter staff and volunteer leaders participating in this annual collaborative event included Missouri, Arkansas, Nebraska, Iowa, Kansas, Illinois, Colorado, Texas, California, Arizona, and Oklahoma. This forum is always an excellent opportunity for learning and networking among peers. Although the warm weather in the middle of February and fish tacos were great, the actionable items and interaction with colleagues was even better.
Dr. Lee Ralph, AAFP Senior Delegate from California, opened the conference on Friday afternoon with a warm California welcome. Dr. Jay Lee, AAFP Board Member and California AFP member moderated a session on Family Medicine Revolution: State Health Reform Focus where representatives from Colorado, Nebraska, and Oklahoma provided perspectives on significant positive state health reform initiatives in their states. Ryan Biehle, Colorado AFP CEO reported on steps his state has taken to reduce administrative burden by limiting prior authorization requirements, Dr. Joseph Miller on Nebraska discussed success they have had in advocating for primary care spending minimums, and Kari Webber, Oklahoma AFP EVP discussed successful strategies in advancing primary care through collaboration with the Oklahoma Health Care Authority. Shawn Martin, AAFP EVP/CEO discussed opportunities and challenges with a new federal administration and explored ways AAFP is keeping the importance of family medicine front and center in Washington, DC. Amanda d’Almedia, MD, MPH, PGY3 and Alex McDonald, MD, FAAFP, CAQSM presented Standing up for Science: How to Message Public Health and Science in the Age of Disinformation which was a comprehensive look on utilizing social media to position family physicians as trusted voices of patient care. Saturday afternoon consisted of individual State report-outs
on two state organizational priorities with MAFP Vice President Lauren Wilfling, DO, FAAFP reporting on behalf of Missouri, an ABFM Update from Gary LeRoy, MD, FAAFP, a session on Artificial Intelligence in Healthcare Information from Dr. Kim Yu, and finished the day with Dr. Russell Kohl, Speaker of the AAFP Congress of Delegates presenting Leading Effective Board Meetings: Lessons From Jazz.
Sunday morning provided attendees with Lessons in Leading: Challenges, Lessons and Best Practices in Physician Leadership. Dr. Rebecca Maddrell, Illinois AFP served as moderator with Dr. Lee Mills, Oklahoma AFP, Delegate; Dr. Lindsay Botsford, Texas AFP; and Dr. Shannon Connolly, Past President, California AFP serving as panelists to examine a variety of leadership roles, the challenges they face, and the joys of leadership.
MAFP Energizes Record-Breaking HOSA Conference
Excitement filled Rolla High School on March 25th, 2025, as MAFP joined the record-breaking Missouri HOSA – Future Health Professionals – State Leadership Conference. With 2,304 participants from 104 local chapters, this year’s event showcased the passion and potential of Missouri’s future healthcare leaders.
HOSA is dedicated to preparing middle and high school students for careers in healthcare through leadership development, hands-on experiences, and competitive events. Among those representing MAFP were President Natalie Long, MD, and Past President Jonathan Paulson, MD, who judged the Family Medicine Physician Competitive Event.
Dr. Paulson recalled a standout moment while judging the Family Medicine HOSA competition. “One student said they see their doctor, ‘well, you know, after you look it up on Google,’ and this really stuck with me,” Paulson said. “On the one hand, I shake my head at Dr. Google, but on the other hand, I see this as a patient engaging their healthcare by attempting to educate themselves.”
“Engaging students interested in Family Medicine is always so exciting. That day, I stepped away from Medical Students and Residents and got to interact with middle and high school students,” Paulson added.
Later that day, Dr. Long and Dr. Paulson addressed a packed room of students eager to explore family medicine.
We told them, “YOU are the future of Family Medicine,” Dr. Paulson said. “Maybe there’s a young Family Medicine physician out there who will figure out how to navigate Google’s complex algorithm and direct curious patients to us for education and care. With AI, virtual visits, and evolving healthcare access, I’m hopeful family physicians will find ways to use these tools to enhance patient education and relationships.”
Dr. Long also shared her reflections: “This past week I had
the pleasure of judging the ‘Family Medicine’ competition at the Missouri HOSA event. Hearing about our specialty through the lens of high school students was a fun and unique way to spend the day. In general, they understood that family physicians are comprehensive primary care doctors who care passionately about their patients and communities. We also spoke to future health professionals about the unique and special job we have as family physicians. Their energy and enthusiasm is boundless!”
Simultaneously, MAFP Member Experience Manager Andrea Holloway, along with Dr. Long and Dr. Paulson when not busy, hosted a booth in the lively HOSA ZONE. This interactive space offered exhibitors, games, and networking opportunities. MAFP encouraged students to take photos with a “Future Family Physician” sign, answered questions about family medicine, and highlighted benefits of becoming a family physician.
With another successful HOSA conference in the books, the future of healthcare in Missouri looks brighter than ever. The enthusiasm and dedication of these students prove that the next generation of family physicians is ready to lead.
Records Set in 2025 Match
The 2025 National Residency Match Program (NRMP) had the most family medicine positions available in history marking the 16th straight year of growth in positions offered. Family medicine offered 5,379 positions, 138 more than in 2024, and 13.4% of positions offered in all specialties.
A total of 4,574 medical students and graduates matched to family medicine residency program this year. Here’s a breakdown of those matches:
• 1,519 U.S. allopathic medical school (MD) seniors
• 1,486 U.S. osteopathic medical school (DO) seniors
• 626 U.S. international medical graduates (IMGs)
• 801 non-U.S. IMGs
• 90 previous graduates of U.S. MD-granting schools
• 52 previous graduates of U.S. DO-granting schools
The Missouri Academy of Family Physicians is excited to support medical students entering Missouri family medicine residency programs and would like to extend a warm welcome to those coming from out-of-state schools. Congratulations to all!
Data from nrmp.org and aafp.org.
Mirdhula Ananthamurugan matched into Mercy Family Medicine residency program.
Tiffany Trzupek matched into University of Missouri Columbia Family Medicine residency program.
Kristen Scholl matched into St. Luke’s Des Peres Hospital Family Medicine residency program.
Shaun Shetty matched into St. Luke’s Des Peres Hospital Family Medicine residency program.
Gabriel Andraus matched into University of Missouri Kansas City Family Medicine residency program.
Katie Long matched into University of Missouri Columbia Family Medicine residency program.
Community Health Center Leader Honored for Advocacy at NACHC Policy & Issues Forum
The National Association of Community Health Centers (NACHC) has honored Catherine R. Moore, DO, FAAFP from Affinia Healthcare in St. Louis, Missouri with the Elizabeth K. Cooke Grassroots Advocacy Award. This award recognizes advocates’ dedication and mobilization efforts to generate public and political support for the nation’s Community Health Centers. Dr. Moore was presented the award during NACHC’s 2025 Policy and Issues Forum (P&I) in Washington, D.C. The annual conference draws thousands of health center leaders from around the country to gather and focus on strategies that expand access to affordable primary care services in underserved communities.
When asked why she is inspired to advocate for community health centers, Dr. Moore remarks, “My personal mission is to seek the peace and prosperity of the North Side of St. Louis, and practicing medicine at Affinia Healthcare, a Community Health Center deeply rooted in our community, is a fulfilling way to live out my mission.”
Thank you, Dr. Moore, for your tireless efforts in supporting equitable healthcare for all!
Cessac Featured in AAFP Blog
Mikala Cessac, MAFP Member and Student Member of the AAFP Board of Directors shares about her love for the specialty of family medicine in a recent blog from the AAFP. Read it online at: https://www.aafp.org/news/ blogs/aafp-voices/choosing-family-medicine-wholepatient.html.
Local Chapter Installs New Officers
Kansas City Academy of Family Physicians (KCAFP) members recently met and installed new officers. Congratulations to KCAFP President Chelsie Cain, DO; Vice President Peter Lazarz, MD and Secretary/ Treasurer Larry Gibbs, MD! More information on this local chapter can be found on our website https://www.moafp.org/about/chapters/kc/.
The Affinia Healthcare Family Medicine Residency program is now recruiting applicants for the inaugural 2026-2027 academic year.
Affinia Healthcare received a $500,000 Teaching Health Center Planning and Development Program grant from the Health Resources and Services Administration (HRSA) to create a residency program to train the next generation of Family Medicine physicians for community health centers.
Affinia Healthcare’s Family Medicine residency program is in partnership with A.T. Still University, Christian Hospital and SSM Health DePaul Hospital. The planning and implementation will have a focus on training future primary care physicians for service at Affinia Healthcare and in the community health center environment.
“Statistics show that many patients in underserved communities suffer or experience a lower standard of care when seeing providers who don’t understand or have bias toward certain populations,” said Dr. Melissa Tepe, Affinia Healthcare Chief Medical Officer. “It is imperative that we cultivate a new generation of clinicians who will know how to serve these populations. The Family Medicine Residency program is another way Affinia Healthcare can help provide a better quality of care for our patients and communities.”
The Affinia Healthcare Family Medicine Residency program is pending accreditation by the Accreditation Council for Graduate Medical Education. Residency program leaders plan
MU Chief Resident Leadership Workshop
The University of Missouri Family Medicine
Residency is hosting a Chief Resident Leadership Workshop on Monday, April 28th, 2025. The event aims to empower your leadership skills, connect you with peers, and learn from experienced Chief Residents.
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Affinia Healthcare to Open Application Process for New Family Residency Program
to start the recruitment process this spring, lining up visits to colleges and universities in the Midwest.
“The right students in this program will not only help establish our program as a premier training opportunity, it will also help define what community medicine looks like in the future,” said Dr. Kenneth Hemba, Family Medicine Residency Program Director. “Our faculty members are committed to providing high-quality care in the community health center setting and consider it an honor to help prepare the next generation of community medicine physicians.”
The inaugural class of residents will also step into the program as trailblazers, the first to embark on this unique training model. The residency curriculum centers on Primary Care and Community Medicine (PCCM), a longitudinal outpatient experience spanning all three years of residency. PCCM incorporates training in elements of primary care such as pediatrics, sports medicine and behavioral health with ample time for each resident’s continuity panel. This format prepares residents for the dynamic requirements of independent fullspectrum Family Medicine practice.
“The Family Medicine Residency curriculum will provide a well-rounded and rigorous experience, allowing residents to acquire the skills, compassion and resilience needed to care for under-resourced and marginalized populations,” Dr. Hemba continued.
References
Carving Your Own Path: Subspecialty Fellowships and Tracks in
Family Medicine
pages 8
1. Fellowship Directory. American Academy of Family Physicians. https://www. aafp.org/medical-education/directory/fellowship/search
2. Sonoda K, Morgan ZJ, Peterson LE. Scope of Practice Intentions Among Family Medicine Residents for Integrated Care of HIV and Hepatitis C Infection in People With Opioid Use Disorder. Fam Med. 2025;57(1):41-47. doi:10.22454/ FamMed.2024.703890
3. Sonoda K, Morgan ZJ, Peterson LE. HIV Care by Early-Career Family Physicians. Fam Med. 2021;53(9):760-765. doi:10.22454/FamMed.2021.415039
Heart Failure with Preserved Ejection Fraction: A Guide for Primary
Care Physicians
pages 9
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