Dr. Robert Baldor

Common dermatologic and benign skin findings:
This presentation will overview basic dermatologic terminology and review the diagnosis and treatment of common and curious skin findings. The presentation is interactive – with participants challenged to diagnose various skin diseases based on projected images. Although the main focus is on benign conditions, we will highlight red flag that may signal a more serious concern.

Managing the Red or Injured Eye:
This presentation will overview the basic anatomy of the eye and ensure that the participants are able to accurately describe abnormal findings, and the component of the eye that is involved, such that the diagnosis and/or communication with a consulting ophthalmologist is clear. Images of common conditions will foster an understanding of the approach to diagnosis of the underlying etiology for the red or injured eye. Treatment options will be presented as well.

Adult Obesity Management:
Mindful eating for patients with obesity. This presentation will reviews of the strategies for helping our overweight and obese patients lose weight from motivational interviewing techniques to dietary and pharmacologic interventions. The criteria and methods for surgical treatment will also be addressed.

Wound Care Management:
The art and science of wound healing: This presentation will review the evaluation for the various types of chronic wounds, whether due to neuropathic or vascular etiologies. The diagnostic approach and treatment along with guidance for wound management will include indications for antibiotics and debridement, along with understanding evidenced-based dressing and ancillary care options.

Dementia and Alzheimer’s disease:
This problem- based learning session will be an interactive case-based format with discussion on the best approach to a patient presenting with concerns for cognitive decline, using tools from the AAFP Cognitive Care Kit. The PBL format allows for peer-to-peer learning with expert over view and commentary. Issues addressed will range from Screening and diagnosis to treatment modalities to address common behavioral problems that accompany cognitive decline.

Dr. Jonathon Firnhaber

ACS in Women
Acute coronary syndrome affects men more often than premenopausal women; after menopause the prevalence of ACS is nearly equal in men and women. Women with ACS may have a less typical presentation, which can lead to a delay in accurate diagnosis. Once properly diagnosed, the treatment and follow-up of ACS in women is no different than in men. This presentation will outline the prevention of cardiovascular disease in women, highlight gender-specific differences in ACS, and will emphasize appropriate post-ACS care.

Nail disorders
Nail disorders are common problems seen by a busy family physician. Virtually all nail disorders can easily be diagnosed and managed in a typical office setting. This presentation will review the practical approach to, as well as pharmacologic and surgical treatment of: ingrown nails, onychomycosis, and dystrophic nails. Prevention strategies will be discussed, and extensive photos and brief videos will illustrate key points.

Fibromyalgia
Fibromyalgia can be difficult to accurately diagnose and even more difficult to successfully manage. While recent changes in diagnostic guidelines have added more objective criteria to a largely subjective disorder, many family physicians find it challenging to offer a treatment plan that is both effective and safe. This presentation will review diagnostic criteria for fibromyalgia and will focus on management strategies that minimize the risk of medication dependence and misuse.

Diabetes complications
Type 2 diabetes mellitus is an extraordinarily common problem worldwide. Well-accepted, evidence-based guidelines have helped busy clinicians adopt a more standardized approach to blood sugar management but are less comprehensive in their recommendations for prevention and treatment of common complications of diabetes. This presentation will review several recent changes in the treatment approach to diabetes and will emphasize the clinical approach to key complications of diabetes, including hypoglycemia, peripheral neuropathy, cardiovascular disease, and chronic kidney disease.

Dr. Joseph Garry

Polymyalgia Rheumatica & Myositis: Oh, My Aching Muscles
Polymyalgia rheumatica (PMR) is the 2nd most common autoimmune disorder and affects predominantly those over age 50 and of Scandinavian and northern European descent. The clinical presentation of PMR includes a rapid onset of bilateral pain, restricted range of motion and stiffness (>30-45 minutes) involving the shoulder girdle, neck, or pelvic girdle in older patients. Muscle weakness is notably absent which helps to differentiate PMR from other types of myositis. Inflammatory markers, such as the erythrocyte sedimentation rate and C-reactive protein are elevated in PMR, and the condition rapidly responds to low dose prednisone. PMR is also associated with Giant Cell Arteritis and 10-20% of patients with PMR will also be diagnosed with arteritis, requiring different diagnostic strategies and initial treatment with higher doses of prednisone.

Fracture Management: Breaks for the FP to Fix
Fractures occur commonly as the result of trauma or falls and most are cared for in the outpatient setting. Diagnosing a fracture requires imaging which first starts with radiographs and occasionally will require advanced imaging. Immobilization is the treatment of choice for a fracture and this is obtained either through splinting, casting or the use of prefabricated braces. In this presentation we will review the diagnosis and management of pediatric fractures, common upper extremity and lower extremity fractures, as well as stress and insufficiency fractures.

PBL: Fracture Management: Breaks for the FP to Fix
This is a case-based interactive learning session that will build upon the knowledge gained in the associated Fracture Management lecture. The audience will work in groups to develop strategies for the assessment, diagnosis and management of fractures that can be cared for in the Family Medicine outpatient setting.

Practical Approaches to Low Back Pain in Primary Care
Low back pain (LBP) is the 5th most common reason why patients visit a physician and account for nearly 15% of new patient visits in primary care. The most common diagnoses for patients presenting with LBP are predominantly benign and include strains, sprains or degenerative changes. Lumbar disc related changes, osteoporotic vertebral compression fractures, and lumbar spinal stenosis account the vast bulk of the remaining diagnoses. This presentation will review the physical examination of the lumbar spine, indications for imaging, and specific evidence-based management strategies for specific lumbar conditions. We will review updates from the American College of Physicians on the management of acute and chronic non-discogenic LBP, as well as evidence regarding the use of opiates in the management of LBP.

Dr Eddie Needham

Cardiovascular Physical Exam: Putting your Finger on the Pulse
This presentation reviews the pertinent cardiovascular examination findings for patients presenting with a new murmur, to include indications for echocardiography.  ECG screening will also be reviewed in the context of the pre-participation examination of the athlete and the risks for sudden cardiac death.  Relevant cardiac murmurs will be demonstrated, and diagnostic ECGs will be reviewed.

The Challenge of the Limping Child
This presentation reviews the etiologies of children with a limp.  Common conditions include transient tenosynovitis, slipped capital femoral epiphysis, Legg-Calve-Perthes disease, septic arthritis, and others.  The history and physical exam findings will be reviewed, as will lab and radiology tests.  The treatment options for each entity will be presented, to include medical and surgical therapies.

Top 10 Evidence-based medicine updates
This presentation will review the most significant updates in family medicine over the past year.  These updates will cover hypertension, hyperlipidemia, diabetes, asthma, back pain, prostate cancer screening, and other topics.  The presentation will also demonstrate ways in which to best access updates to family medicine.

Cardiovascular Pharmacology
This presentation will review the most recent Guideline-Directed Medical Therapy (GDMT) for hypertension, hyperlipidemia, heart failure, stroke, and stable coronary artery disease (CAD).  In many instances, the therapeutic interventions overlap between conditions, e.g., statin therapy.  And in other cases, therapies are divergent: dual-antiplatelet therapy (DAPT) for patients with CAD status post PCI, while patients status post stroke receive either aspirin or clopidogrel, but not both.  The talk will also cover the recent literature on the use of aspirin for primary prevention of CAD.

Physician Wellbeing – Becoming a More Relaxed, Healthier Physician: Reducing Frustration and Increasing Fulfillment
Physician burnout in family medicine is a significant headwind in 2018.  This presentation addresses techniques at the physician and organization level that can build resilience and wellbeing.  Mindfulness and reframing will be discussed, as will the challenge of dealing with difficult emotions.  The intent of the talk is to enable physicians to address their own wellness and lead their staff in stepping forward into the light of a fulfilled life.

Dr. Margot Savoy

Adolescent Depression Management and Bullying Mitigation: Interventions That Make A Difference
Margot Savoy, MD, MPH, FAAFP, FABC, CPE, CMQ

Learning Objectives:
1. Utilize appropriate diagnostic criteria to evaluate and screen adolescent patients for depression, bullying, mood disorders, and suicide risk.
2. Counsel parents and adolescent patents regarding bullying prevention and intervention.
3. Devise collaborative treatment plans, including appropriate psychotherapy and pharmacotherapy (or a combination), that take into account the risks and benefits of various interventions.
4. Coordinate care for adolescent patients who require referral to sub-specialists or admission to hospitals for suicide prevention.

Abstract:
Bullying refers to aggressive behavior between school-aged youth when there is a power imbalance that is repeated, or has the potential to be repeated, over time. It can include physical, verbal or social aggression. Bullying is quite common with an estimated 20% of youths reporting being bullied on school property within the previous year, and 16% were cyberbullied. Young people who are bullied and who bully others are at the highest risk for negative outcomes such as anxiety and depression, suicidality, substance use and decreased academic achievement leading to diminished earning potential. Teenagers should be routinely screened for depression. Multidisciplinary treatment plans for addressing adolescent depression should engage the patient and parent to address underlying causes including mitigating bullying, assessing suicide risk and when appropriate counseling with or without medication.

References:
Gladden, R. M., Vivolo-Kantor, A. M., Hamburger, M. E., & Lumpkin, C. D. (2014).Bullying surveillance among youths :Uniform definitions for public health and recommended data elements. Retrieved November 29, 2018 from https://www.cdc.gov/violenceprevention/pdf/bullying-definitions-final-a.pdf – PDF.
S. Department of Health and Human Services. (2017). What Is Bullying. Retrieved November 29, 2018 from https://www.stopbullying.gov/what-is-bullying/index.html
Stephens MM, Cook-Fasano HT, Sibbaluca K. Childhood Bullying: Implications for Physicians. Am Fam Physician. 2018 Feb 1;97(3):187-192.
Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance —United States, 2015. MMWR Surveill Summ. 2016;65(6):1–174.
Buxton D, Potter MP, Bostic JQ. Coping strategies for child bully-victims. Pediatr Ann. 2013;42(4):57–61.
Patchin, J. W. (2017). Millions of students skip school each year because of bullying. Retrieved November 29, 2018 from http://cyberbullying.org/millions-students-skip-school-year-bullying
Wolke, D., Copeland, W. E., Angold, A., & Costello, E. J. (2013). Impact of bullying in childhood on adult health, wealth, crime, and social outcomes. Psychological science, 24(10), 1958-1970.
The National Academic of Sciences, Engineering, and Medicine (2016). Preventing bullying through science, policy, and practice.Retrieved November 29, 2018 from http://www.apa.org/act/resources/webinars/bullying-bradshaw-flannery.pdf – PDF
American Academy of Pediatrics. Bullying and Cyberbullying. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Bullying-and-Cyberbullying.aspx. Accessed on November 29, 2018.
United States Preventive Services Task Force. Depression in Children and Adolescents. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-children-and-adolescents-screening1. Accessed on November 29, 2018.
Centers for Disease Control and Prevention. Children’s Mental Health. https://www.cdc.gov/childrensmentalhealth/depression.html. Accessed on November 29, 2018.
Bridge JA, Salary CB, Birmaher B, Asare AG, Brent DA. The risks and benefits of antidepressant treatment for youth depression. Ann Med. 2005;37(6):404–412. pmid:16203613.
Centers for Disease Control and Prevention. 2017 Youth Risk Behavior Survey Data. Available at: cdc.gov/yrbs. Accessed on November 29, 2018.

Adolescent Depression Management and Bullying Mitigation: Interventions That Make A Difference [PBL Session]
Margot Savoy, MD, MPH, FAAFP, FABC, CPE, CMQ

Learning Objectives:
1. Practice applying new knowledge and skills gained from Adolescent Depression Management and Bullying Mitigation session, through collaborative learning with peers and expert faculty.
2. Identify strategies that foster optimal management of adolescent depression and bullying mitigation, within the context of professional practice.
3. Formulate an action plan to implement practice changes aimed at improving patient care.

Abstract:
Bullying refers to aggressive behavior (physical, verbal or social) between school-aged youth when there is a power imbalance that is repeated, or has the potential to be repeated, over time. It is quite common and these young people are at increased risk of negative outcomes. Family physicians should be comfortable using standardized tools to assess depression, asking questions to assess risk of bullying and suicidality and developing treatment plans that engage the patient/parent and leverage appropriate professionals.

References:
Gladden, R. M., Vivolo-Kantor, A. M., Hamburger, M. E., & Lumpkin, C. D. (2014).Bullying surveillance among youths: Uniform definitions for public health and recommended data elements. Retrieved November 29, 2018 from https://www.cdc.gov/violenceprevention/pdf/bullying-definitions-final-a.pdf – PDF.
S. Department of Health and Human Services. (2017). What Is Bullying. Retrieved November 29, 2018 from https://www.stopbullying.gov/what-is-bullying/index.html
Stephens MM, Cook-Fasano HT, Sibbaluca K. Childhood Bullying: Implications for Physicians. Am Fam Physician. 2018 Feb 1;97(3):187-192.
Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance —United States, 2015. MMWR Surveill Summ. 2016;65(6):1–174.
Buxton D, Potter MP, Bostic JQ. Coping strategies for child bully-victims. Pediatr Ann. 2013;42(4):57–61.
Patchin, J. W. (2017). Millions of students skip school each year because of bullying. Retrieved November 29, 2018 from http://cyberbullying.org/millions-students-skip-school-year-bullying
Wolke, D., Copeland, W. E., Angold, A., & Costello, E. J. (2013). Impact of bullying in childhood on adult health, wealth, crime, and social outcomes. Psychological science, 24(10), 1958-1970.
The National Academic of Sciences, Engineering, and Medicine (2016). Preventing bullying through science, policy, and practice.Retrieved November 29, 2018 from http://www.apa.org/act/resources/webinars/bullying-bradshaw-flannery.pdf – PDF
American Academy of Pediatrics. Bullying and Cyberbullying. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Bullying-and-Cyberbullying.aspx. Accessed on November 29, 2018.
United States Preventive Services Task Force. Depression in Children and Adolescents. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-children-and-adolescents-screening1. Accessed on November 29, 2018.
Centers for Disease Control and Prevention. Children’s Mental Health. https://www.cdc.gov/childrensmentalhealth/depression.html. Accessed on November 29, 2018.
Bridge JA, Salary CB, Birmaher B, Asare AG, Brent DA. The risks and benefits of antidepressant treatment for youth depression. Ann Med. 2005;37(6):404–412. pmid:16203613.
Centers for Disease Control and Prevention. 2017 Youth Risk Behavior Survey Data. Available at: cdc.gov/yrbs. Accessed on November 29, 2018.

Burned Out or Fired Up? Transforming You, Your Team, and Your Culture
Margot Savoy, MD, MPH, FAAFP, FABC, CPE, CMQ

Learning Objectives:
Describe burnout and resiliency
Identify signs of burnout in yourself and others
Use at least 1 new burnout prevention strategy
Locate physician burnout resources for later

Abstract:
Burnout is the exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration. Some estimates report nearly half of physicians have symptoms of burnout. ¼ of doctors are leaving medicine annually in the US, and this number is expected to rise. A physician suffering from burnout typically follows one of four pathways: (1) recognize, change and recover, (2) develop a chronic condition with disruptive behavior, (3) develop a complication (abuse/addiction, divorce, depression, suicide) or (4) quit medicine for a new career or retirement. There are a number of strategies you can use to try and mitigate the effect of burnout including developing gratitude practices, identifying a boundary ritual, hacking your schedule and learning to breathe/meditate.

References:
Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: can you make the switch? Fam Pract Manag. 2013 Jan-Feb;20(1):25-30.
Phillips,D. One in Four Physicians Rethinking Clinical Practice. Medscape Family Medicine. https://www.medscape.com/viewarticle/887940. Accessed on 11-30-2018.
The Advisory Board. Doctors leaving the Profession. https://www.advisory.com/daily-briefing/2016/09/26/doctors-leaving-profession. Accessed on 11-30-2018.
Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-31.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704134/. Accessed on 11-30-2018.
Anderson,P. Physicians Experience Highest Suicide Rate of Any Profession. Medscape Family Medicine. https://www.medscape.com/viewarticle/896257. Accessed on 11-30-2018.
Drummond, D. Work Life Balance Schedule Hack for Busy Doctors. https://www.thehappymd.com/blog/bid/289962/Work-Life-Balance-Schedule-HACK-for-Busy-Doctors. Accessed on 11-30-2018.
Drummond, D. Physician Burnout Prevention Matrix. https://support.thehappymd.com/physician-burnout-prevention-matrix. Accessed on 11-30-2018.
Martin M, Salzberg L, Andolsek KM, Teasley D. Physician Well-Being. FP Essent. 2018;471:1-40.
Drummond, D. Eight Ways to Lower Practice Stress and Get Home Fam Pract Manag 2015; 22(6):13-18.
Drummond, D. Physician Burnout: Its Origins, Symptoms, and Five Main Causes. Fam Pract Manag 2015; 22(5):42-47.
Grohol, JM. 15 Common Cognitive Distortions. PsychCentral. https://psychcentral.com/lib/15-common-cognitive-distortions. Accessed on 11-30-2018.
Rotenstein LS,Torre M, Ramos MA5, Rosales RC, Guille C, Sen S, Mata DA. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018 Sep 18;320(11):1131-1150. doi: 10.1001/jama.2018.12777.

Creating a Thriving Practice Culture – By Design
Margot Savoy, MD, MPH, FAAFP, FABC, CPE, CMQ

Learning Objectives:
1. Identify key characteristics of the practice environment that influence individual and team satisfaction.
2. Describe their present practice culture and apply a framework to envision their ideal practice culture.
3. Develop a plan to help lead their practice to a higher level of enjoyment in providing care.

Abstract:
Stressful work environments often lead physicians and their staff to adopt survival behaviors that help them make it through the day. Culture is the way a group thinks, acts, and interacts. Culture is composed of the behaviors, beliefs, values, and symbols the group accepts, often without thinking about them. They are passed along by communication and imitation from person to person over time. Practice cultures tend to develop by default and without intentional work and development can contribute to job dissatisfaction and burnout. Physician leaders who address six key qualities of well-functioning teams (Service, Teamwork, Attitude, Reflection, Renewal and Self-care) will benefit by have a team who experiences high levels of well-being.

References:
Greenawald MH. How to Create a Culture of Well-Being in Your Practice. Fam Pract Manag. 2018 Jul/Aug;25(4):11-15.
Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general U.S. working population between 2011 and 2014 [published correction appears in Mayo Clin Proc. 2016;(91)2:276]. Mayo Clin Proc. 2015;90(12):1600–1613.
Kuzel AJ. Ten steps to a patient-centered medical home. Fam Pract Manag. 2009;16(6):18–24.
Greenleaf RK. The Servant as Leader. Indianapolis, IN: Robert K. Greenleaf Center; 1991.
Frankl VE. Man’s Search for Meaning: An Introduction to Logotherapy. New York: Simon & Schuster; 1984.
Losada M, Heaphy E. The role of positivity and connectivity in the performance of business teams. Am Behav Sci. 2004;47(6):740–765.
Weinstock D. Defining the culture of your practice. J Med Pract Manage. 2014 Sep-Oct;30(2):94-6.
Hills L. How to be a better team player: fifty strategies. J Med Pract Manage. 2012 Sep-Oct;28(2):125-9.

Office Immunization Management: It Takes a Team!
Margot Savoy, MD, MPH, FAAFP, FABC, CPE, CMQ

Learning Objectives:
1. Use evidence-based recommendations and guidelines to establish standardized vaccine administration procedures, including standardized protocols to screen for immunizations during adult, child, and adolescent patient encounters.
2. Identify opportunities to participate in community discussions, community meetings, and informational campaigns to increase immunization uptake in the local community.
3. Participate in available childhood immunization and registry programs and administer using a standardized process.
4. Establish practices that optimize reimbursement for the provision of immunizations.

Abstract:
Recommending and administering immunizations is a key service in family physicians’ offices. Developing a successful immunization program within your practice offers an opportunity for physicians to engage other key members of the team to lead. One approach that has been successful in improving immunization rates is the office champion model where the practice empowers a non-physician team member with the support of the lead physician to lead and engage the practice in quality improvement efforts. Four components to successful office immunization management include empowering an office champion, using quality improvement to identify and address opportunities, implementing evidence-based guidelines and practices and sharing your practice success with the world.

References:
Walker TY, Elam-Evans LD, Singleton JA, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2016. MMWR Morb Mortal Wkly Rep 2017; 66:874–882. DOI: http://dx.doi.org/10.15585/mmwr.mm6633a2
Zimmerman RK, Santibanez TA, Fine MJ, et al. Barriers and facilitators of pneumococcal vaccination among the elderly. 2003;21(13-14):1510-1517.
Centers for Disease Control and Prevention (CDC). National Ambulatory Medical Care Survey. In: Ambulatory and Hospital Care Statistics Branch,
Zimmerman RK, Silverman M, Janosky JE, et al. A comprehensive investigation of barriers to adult immunization: a methods paper. The Journal of family practice. 2001;50(8):703.
Zimmerman RK, Nowalk MP, Tabbarah M, Hart JA, Fox DE, Raymund M. Understanding adult vaccination in urban, lower-socioeconomic settings: influence of physician and prevention systems. Annals of family medicine. 2009;7(6):534-541.
Santibanez TA, Nowalk MP, Zimmerman RK, et al. Knowledge and beliefs about influenza, pneumococcal disease, and immunizations among older people. J Am Geriatr Soc. 2002;50(10):1711-1716.
Santibanez TA, Zimmerman RK, Nowalk MP, Jewell IK, Bardella IJ. Physician attitudes and beliefs associated with patient pneumococcal polysaccharide vaccination status. Annals of family medicine. 2004;2(1):41-48.
Campos-Outcalt D, Jeffcott-Pera M, Carter-Smith P, Schoof BK, Young HF. Vaccines provided by family physicians. Annals of family medicine. 2010;8(6):507-510.
Hainer BL. Vaccine administration: making the process more efficient in your Family practice management. 2007;14(3):48-53.
Phadke VK, Bednarczyk RA, Salmon DA, Omer SB. Association Between Vaccine Refusal and Vaccine-Preventable Diseases in the United States: A Review of Measles and Pertussis. JAMA : the journal of the American Medical Association. 2016;315(11):1149-1158.
Davis MM. Toward High-Reliability Vaccination Efforts in the United States. JAMA : the journal of the American Medical Association. 2016;315(11):1115-1117.
Ackerman LK, Serrano JL. Update on Routine Childhood and Adolescent Immunizations. American family physician. 2015;92(6):460-468.
Vaughn JA, Miller RA. Update on immunizations in adults. American family 2011;84(9):1015-1020.
Ackerman LK. Update on immunizations in children and adolescents. American family physician. 2008;77(11):1561-1568.
Savoy M. ACIP Releases 2016 Childhood Immunization Recommendations. American family physician. 2016;93(4):317-322.
Appel A. Improving adult immunization rates: overcoming barriers. American family physician. 2011;84(9):977-978.
Brown MT, Mena Lora A, Anderson MC, Sinsky CA. Resolving patients’ vaccination uncertainty: going from “no thanks!” to “of course!”. Family practice management. 2014;21(2):22-26.
Cayley WE, Jr. Interventions Aimed at Increasing Childhood Vaccination American family physician. 2015;92(9):775-776.
Porter S. Physician Participation Key to Role Immunization Registries Play in Vaccination Efforts. AAFP News.
Loehr J. Immunizations: how to protect patients and the bottom line. Family practice management. 2015;22(2):24-29.
American Academy of Family Physicians (AAFP). AAFP Immunization Schedules. 2018.
Nguyen GT, Klusaritz HA, Cronholm PF. Achieving sustainable increases in childhood immunization rates. Family practice management. 2014;21(4):13-17.
American Academy of Family Physicians (AAFP). Coding for Vaccine Administration. 2015.
Lin K. ACP Immunization Advisor. Family practice management. 2013;20(6):30.
Mauksch L, Safford B. Engaging Patients in Collaborative Care Plans. Family practice management. 2013;20(3):35-39.
McLeod W, Eidus R, Stewart EE. Clinical decision support: using technology to identify patients’ unmet needs. Family practice management. 2012;19(2):22-28.
Owolabi T, Simpson I. Documenting and coding preventive visits: a physician’s perspective. Family practice management. 2012;19(4):12-16.
Stewart EE, Fox CH. Encouraging patients to change unhealthy behaviors with motivational interviewing. Family practice management. 2011;18(3):21-25.

Urinary Incontinence and Urinary Frequency
Margot Savoy, MD, MPH, FAAFP, FABC, CPE, CMQ

Learning Objectives:
1. Incorporate current guidelines for diagnosis in patients presenting with urinary problems.
2. Coordinate referral to a urologist or urogynecologist if initial diagnosis is unclear; or red flags such as hematuria, obstructive symptoms or recurrent urinary tract infections are present.
3. Counsel patients regarding first-line treatment options, including behavioral therapy and lifestyle modifications, emphasizing adherence and follow-up.
4. Prescribe second or third-line treatment options if first-line therapies are unsuccessful, coordinating referral and follow-up care for surgical treatment as necessary.

Abstract:
Urinary symptoms are common causes of significant distress for many. While 16.9% women and 16% of men in the United Stated have symptoms including increased urinary frequency suggestive of an overactive bladder, many hesitate to report their concerns to physicians due to embarrassment, nervousness or a misunderstanding of the normal aging process. Overactive Bladder Syndrome (OAB) typically present with lower urinary tract symptoms suggestive of involuntary bladder contractions including urgency, frequency and nocturia. While not all patients will experience urinary incontinence as part of their syndrome, a significant number will. Behavioral techniques, medications and supportive aides can be used in the management of OAB and urinary incontinence to improve symptoms and quality of life.

References:
FitzGerald, M.P. et al. Urinary habits among asymptomatic women. American Journal of Obstetrics & Gynecology. Vol187:(5): 1384 – 1388.
Lukacz ES, Sampselle C, Gray M, et al. A healthy bladder: a consensus statement. International journal of clinical practice. Oct 2011;65(10):1026-1036.
Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Subcommittee of the International Continence Neurourol Urodyn. 2002. 21(2):16778.
Lukacz ES, Sampselle C, Gray M, et al. A healthy bladder: a consensus statement. International journal of clinical practice. Oct 2011;65(10):1026-1036.
Milsom I, Abrams P, Cardozo L, Roberts RG, Thüroff J, Wein AJ. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 2001 Jun. 87(9):7606.
Nitti VW. Clinical Impact of Overactive Bladder. Reviews in Urology. 2002;4(Suppl 4):S2-S6.
Coyne KS, Sexton CC, Irwin DE, Kopp ZS, Kelleher CJ, Milsom I. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU international. Jun 2008;101(11):1388-1395.
Lachs, M. et al. (1997a). ED Use by Older Victims of Family Violence. Annals of Emergency Medicine, 30:4, 448 – 454.
Coyne KS, Sexton CC, Vats V, Thompson C, Kopp ZS, Milsom I. National community prevalence of overactive bladder in the United States stratified by sex and age. Urology. May 2011;77(5):1081-1087.
Landefeld CS, Bowers BJ, Feld AD, et al. National Institutes of Health state-of-the-science conference statement: Prevention of fecal and urinary incontinence in adults. Ann Intern Med 2008;148:449–458.
Gorina Y, Schappert S, Bercovitz A, et al. Prevalence of incontinence among older Americans. Vital Health Stat 3 2014;36:1–33
Corcos J, Przydacz M, Campeau L, et al. CUA guideline on adult overactive bladder. Can Urol Assoc J. 2017;11(5):E142-E173.
Nambiar AK, Bosch R, Cruz F, et al. EAU Guidelines on Assessment and Nonsurgical Management of Urinary  Eur Urol 2018;73(4):596-609
National Collaborating Centre for Women’s and Children’s Health. Urinary incontinence: the management of urinary incontinence in women. London (UK): National Institute for Health and Care  Excellence (NICE); 2013 Sep. 48 (Clinical guideline; no. 171).
Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P, Clinical Guidelines  Committee of the American College of  Nonsurgical management of urinary incontinence in women: a clinical  practice guideline from the American College  of Physicians(ACP). Ann Intern Med. 2014 Sep 16;161(6):429-40

Attack the WAC (Work After Clinic): Building Resilience and Efficiency
Margot Savoy, MD, MPH, FAAFP, FABC, CPE, CMQ

Learning Objectives:
1. Determine feasible opportunities to utilize and optimize existing technology to enhance access, patient self-management, quality and coordination of care, etc.
2. Identify new technologies on the horizon that may resolve current challenges in delivering quality, cost effective care.
3. Evaluate existing workflows to determine practice ability to optimize new and existing technologies.

Abstract:
Work after clinic refers to the administrative tasks required to manage patient care between visits. A significant cause of burnout and demoralization, many family physicians find they spend more hours managing the paperwork and administrative hurdles associated with the patient visit than actually delivering face to face care. For every hour primary care physicians spends in direct patient care, physician spend two hours engaged in administrative functions. Common tasks include electronic medical records tasks (documentation, billing and quality reporting), prior authorizations and referrals, coordination of care between providers. Best practice strategies to reduce WAC include team-based care delivery and documentation, work of redesign with an eye towards delegation, standardization and efficiency and leverage the electronic medical record.

References:
Martin M, Salzberg L, Andolsek KM, Teasley D. Physician Well-Being. FP Essent. 2018;471:1-40.
Gidwani R, Nguyen C, Kofoed A, et.al. Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Ann Fam Med 2017;15:427-433. https://doi.org/10.1370/afm.2122.
Fogarty, Getting Your Notes Done on Time. Fam Pract Manag. 2016 Mar-Apr;23(2):40.
Sinsky, CA, Sinsky, and Rajcevich, E. Putting Pre-Visit Planning Into Practice. Fam Pract Manag. 2015 Nov-Dec;22(6):30-38.
STEPSForward: AMA’s Practice Improvement https://www.stepsforward.org/. Accessed on 11/29/2018.
Hopkins, KD and Sinsky CA. Team-Based Care: Saving Time and Improving Fam Pract Manag. 2014 Nov-Dec;21(6):23-29.
Covey SR. The 7 Habits Of Highly Effective People, London: Simon & Schuster Ltd,
Drummond, D. Eight Ways to Lower Practice Stress and Get Home Fam Pract Manag 2015; 22(6):13-18.
Drummond, D. Physician Burnout: Its Origins, Symptoms, and Five Main Causes. Fam Pract Manag 2015; 22(5):42-47.
Gordon CE, Borkan SC. Recapturing time: a practical approach to time management for physicians. Postgrad Med J 2014; 90:267-272.
Bernard, R. How to be a Rock Star Doctor: The Complete Guide to Taking Back Control of Your Life and Your Rebekah Bernard, Md Pa; 2015.
Woolhandler S, Himmelstein DU. Administrative work consumes one-sixth of U.S. physicians’ working hours and lowers their career satisfaction. Int J Health Serv. 2014;44(4):635-42.
Rao SK, Kimball AB, Lehrhoff SR, Hidrue MK, Colton DG, Ferris TG, Torchiana DF. The Impact of Administrative Burden on Academic Physicians: Results of a Hospital-Wide Physician Survey. Acad Med. 2017 Feb;92(2):237-243. doi: 10.1097/ACM.0000000000001461.
Rotenstein LS,Torre M, Ramos MA5, Rosales RC, Guille C, Sen S, Mata DA. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018 Sep 18;320(11):1131-1150. doi: 10.1001/jama.2018.12777.
Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. ;165:753–760.doi: 10.7326/M16-0961

Dr. David Weissmiller

Gastrointestinal Disorders: GERD, Probiotics, and Peppermint Oil
Gastrointestinal disorders are common. This interactive lecture will examine the current evidence on the treatment and evaluation of GERD, the therapeutic use of probiotics in common gastrointestinal conditions, and the role of peppermint oil on global symptom improvement in individuals who have functional disorders. At the end of this presentation participants will be able to: discuss the common disorder of the esophagus: GERD; identify methods by which intestinal microflora can be altered; discuss mechanisms of action of probiotics; determine appropriate therapeutic use of probiotics in common gastrointestinal conditions; assess the safety of probiotic therapy; correctly identify evidence based probiotic products for gastrointestinal conditions using online tools, apps and websites; and educate patients on selecting an appropriate probiotic and how fermented foods may impact health.

Geriatric Grief Reaction – Grief and Depression in the Elderly
Our population is aging. The prevalence of depression varies widely with some reports suggesting 10-15% of the older population. Geriatric depression may be underdiagnosed by as much as 50% in primary care settings as symptoms tend to be more somatic and less emotional. It can often be difficult to distinguish between grief and depression in an individual. This distinction is made even more difficult when working with the elderly, given that there are typically many other changes taking place at the time of diagnosis. Living in an ageist society stimulates anxiety around the natural process of growing older. This, coupled with the challenges and changes that come with growing older, can make grief and depression in the elderly close bedfellows. At the end of this presentation participants will be able to: distinguish among bereavement, grief, depression, and anxiety; utilize the appropriate depression and anxiety screening tools; implement the new psychiatric collaborative care management process with the appropriate billing requirements.

Why Am I So Sleepy? Evaluation and Treatment of Hypersomnolence
Look around you: the guy nodding off on the bus, the co-worker snoozing during a dull presentation, the people with heavy eyelids lined up at the coffee shop in mid-afternoon. Excessive sleepiness can have serious consequences. One could doze off while waiting at a red light, for example. And not getting good sleep has been associated with high blood pressure, heart disease, diabetes, and weight gain. Is anyone well rested?  At the end of this presentation participants will be able to: state the negative consequences of insufficient sleep to healthy physiological functioning and mental health; compare fatigue and hypersomnolence and use history taking and simple screening tools to measure levels of daytime sleepiness; summarize prescribing stimulant medications for treat people who suffer from hypersomnolence.

Pediatric Obesity
Childhood obesity has immediate and long-term effects on physical, social, and emotional health. Children with obesity are at higher risk of having other chronic health conditions and diseases that influence physical health. These include asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors for heart disease. Additionally, children who are obese are bullied and teased more than their normal weight peers and are more likely to suffer from social isolation, depression, and lower self-esteem. In the long term, a child with obesity is more likely to have obesity as an adult. An adult with obesity has a higher risk of developing heart disease, type 2 diabetes, metabolic syndrome, and many types of cancer. What can we as primary care clinicians do? At the end of this presentation participants will be able to: implement a screening protocol for all children between the ages of 6-18 years in accordance with the USPSTF recommendation; develop an integrated obesity management plan that includes intensive behavioral interventions and encourages whole family involvement; describe a motivational interviewing strategy and explain how that strategy can promote patient behavior change; establish coding practices for appropriate billing for diet and preventive care counseling.

U.S. Preventive Services Task Force – Key Prevention Updates
The United States Preventive Services Task Force (USPSTF) is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. The task force, a panel of primary care physicians and epidemiologists, is funded, staffed, and appointed by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality.  The USPSTF explicitly does not consider cost as a factor in its recommendations, and it does not perform cost-effectiveness analyses. American health insurance groups are required to cover, at no charge to the patient, any service that the USPSTF recommends, regardless of how much it costs or how small the benefit is. At the end of this presentation participants will be able to: implement new recommendations from the USPSTF into practice including recommendations for cervical and prostate cancer screening, behavioral counseling for healthful diet and physical activity, obesity screening, vision screening in children, screening for celiac disease, screening for sleep apnea, screening for thyroid cancer, and other recent changes; access, read, and understand the methods used by and recommendations from the USPSTF; use the evidence supporting the USPSTF recommendations to motivate patients to receive services with clear benefit and engage patients in shared decision-making for decisions with a close balance of benefits and harms.

Dr. Julie Wood

Well Woman Exam: The new Well Woman Visit

Abstract:
This session will provide evidence-based information and updated recommendations for women’s preventive health services, including a framework of eight priority areas for the well woman visit.

Learning objectives:
Conduct age appropriate screening of female patients according to current evidence-based recommendations.
Assess patient’s health risks and counsel patients on necessary lifestyle modifications to maintain health.
Differentiate specific issues, disease processes, and treatments based on ethnicity, gender, and genetics.
Develop a protocol for well-woman screening that encompasses the eight priority areas for well-woman care.

References:
GinossarT, Shah SF, West AJ, et al. Content, Usabilty, and Utilization of Plain Language in Breast Cancer Mobile Phone Apps: A Systematic Analysis. JMIR mHealth and uHealth. 2017; 5(3):e20

https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2016-2018.pdf

Qaseem et al. Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline from the American College of Physicians. Annals of Internal Medicine. 2014; 161(1):67-72. http://annals.org/aim/fullarticle/1884537/screening-pelvic-examination-adult-women-clinical-practice-guideline-from-american Accessed July 6, 2018

Huh WK, Ault KA, Chelmow D, Davey DD, Goulart RA, Garcia FA, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol 2015;125:330–7. Available at: http://journals.lww.com/greenjournal/fulltext/2015/02000/Use_of_Primary_High_Risk_Human_Papillomavirus.8.aspx.

Brown HL et al. Promoting Risk Identification and Reduction of Cardiovascular Disease in Women Through Collaboration With Obstetricians and Gynecologists: A Presidential Advisory From the American Heart Association and the American College of Obstetricians and Gynecologists. Circulation. 2018;137:e843-e852. http://circ.ahajournals.org/content/137/24/e843

https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html

Johnson K et al. Recommendations to Improve Preconception Health and Health Care — United States. MMWR 2006; 55(RR06): 1-23.https://www.cdc.gov/MMWr/preview/mmwrhtml/rr5506a1.htm

Farahi N and Zolotor A. Recommendations for Preconception Counseling and Care. AFP 2013; 88(8): 499-506. https://www.aafp.org/afp/2013/1015/p499.html

Reproductive Life Plan

https://epss.ahrq.gov/PDA/index.jsp

Clinical Transformation-Population Base Care

Abstract:
Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.  This session will discuss practice transformation concepts to address the population health of a practice and the social determinants of health.

Learning Objectives:
Understand the basics of population health management.
Assess social determinants of health of the practice’s patient population.
Describe the value of team-based care for the practice and the patient.
Develop knowledge and skills to apply a population health approach to delivery of primary care services.

References:
AAFP The Everyone Project, AAFP website, 3, 2018.

Bates, David W. et al. Big Data In Healthcare: Using Analytics to Identify and Manage High Risk and High Cost Patients. Health Affairs. 2014: 33(7): 1123-1131.

Bodenheimer, Thomas et al. The 10 Building Blocks or High Performing Primary Care. Annals of Family Medicine. March/April 2014; 12(2): 166-171.

Byhoff, E. et al. Screening for Social determinants of Health in Michigan Health Centers. JABFM 2017: 30 (4): 418-427.

Garg, Avin et al. Avoiding the Unintended Consequences of Screening for Social Determinants of Health. JAMA.com. June 27, 2016.

Lewis, Joy H. et al. Community health center provider ability to identify, treat and account for the social determinants of health: a card study. BMC Family Practice. 17 (1): 121

O’Gurek, David T. et al. A Practical Approach to Screening for Social Determinants of Health. FPM: May-June, 2018: 25 (3): 7-12.

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