Storylines of family medicine IX: people and places-diverse populations and locations of care.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IX: people and places-diverse populations and locations of care', authors address the following themes: 'LGBTQIA+health in family medicine', 'A family medicine approach to substance use disorders', 'Shameless medicine for people experiencing homelessness', '''Difficult" encounters-finding the person behind the patient', 'Attending to patients with medically unexplained symptoms', 'Making house calls and home visits', 'Family physicians in the procedure room', 'Robust rural family medicine' and 'Full-spectrum family medicine'. May readers appreciate the breadth of family medicine in these essays.

Addressing and Dismantling the Legacy of Race and Racism in Academic Medicine: A Socioecological Framework.

Over the past several years, in both clinical and academic medicine, there seems to be a growing consensus that racial/ethnic health inequities result from social, economic and political determinants of health rather than from nonexistent biological markers of race. Simply put, racism is the root cause of inequity, not race. Yet, methods of teaching and practicing medicine have not kept pace with this truth, and many learners and practitioners continue to extrapolate a biological underpinning for race. To achieve systemic change that moves us toward racially/ethnically equitable health outcomes, it is imperative that medical academia implement policies that explicitly hold us accountable to maintain a clear understanding of race as a socio-political construct so that we can conduct research, disseminate scholarly work, teach, and practice clinically with more clarity about race and racism. This short commentary proposes the use of a socioecological framework to help individuals, leadership teams, and institutions consider the implementation of various strategies for interpersonal, community-level, and broad institutional policy changes. This proposed model includes examples of how to address race and racism in academic medicine across different spheres, but also draws attention to the complex interplay across these levels. The model is not intended to be prescriptive, but rather encourages adaptation according to existing institutional differences. This model can be used as a tool to refresh how academic medicine addresses race and, more importantly, normalizes conversations about racism and equity across all framework levels.

Exploring the Face-to-Face: Revisiting Patient-Doctor Relationships in a Time of Expanding Telemedicine.

The patient-doctor relationship lies at the heart of medicine. Confronted with the challenges of COVID-19, we find ourselves unable to provide care and comfort in the same physical space as our patients. As we are forced to reckon with telemedicine visits and contemplate continuing them in a postpandemic future, it is important to understand the difference relationally between telemedicine and face-to-face encounters. I will argue that face-to-face visits remain essential in establishing the most fundamentally human components of relationships: responsibility and vulnerability. This established bond assures fidelity in subsequent encounters, whether by phone, video, or in person.

Dear White People.

We are living in unprecedented times. While the world is grappling with COVID-19, we find the horrors of racism looming equally large as we, yet again, confront lurid deaths in the center of the news cycle of Black and brown people from police bias and brutality. Those of us who have been championing antiracism and justice work and bearing the burden of the "minority tax" have been overwhelmed by sudden asks from our well-intentioned White colleagues of how to best respond. In the tone of the Netflix series, "Dear White People," we further emphasize that we are not alone in trying to reach out to you, our White colleagues and leaders. Please hear our story and heed our call to action.

A Qualitative Study of Undergraduate Racial and Ethnic Minority Experiences and Perspectives on Striving to Enter Careers in the Health Professions.

BACKGROUND: Diversification of the health care workforce by race and ethnicity offers a strategy for addressing health care disparities. This study explored the experiences with pathways programming and mentoring of minority undergraduates aspiring to health professions careers. METHODS: We interviewed 21 minority undergraduates in 4 focus groups. The interviews explored participants' backgrounds; perceptions of racial climate; exposure to health professions careers, mentors, and pathways programs; barriers to success; and desired support. RESULTS: Many participants described diminished confidence and feelings of isolation due to stereotyping and discrimination; some were empowered to pursue health care careers because of adversity. Common themes included desire for mentorship, earlier career exposure, and college readiness support. DISCUSSION: Minority students desire health career exposure, mentoring, pre-college advising, and a positive racial climate; unfortunately, these desires often go unmet.

Finding Hope in the Face-to-Face.

What does it mean to look into the face of a patient who looks back? Face-to-face encounters are at the heart of the patient-clinician relationship but their singular significance is often lost amid the demands of today's high-tech, metric-driven health care systems. Using the framework provided by the philosopher and Holocaust survivor Emmanuel Levinas, the authors explore the unique responsibility and potential for hope found only in face-to-face encounters. Revisiting this most fundamental attribute of medicine is likely our greatest chance to reclaim who we are as clinicians and why we do what we do.

BREATHE OUT: a randomized controlled trial of a structured intervention to improve clinician satisfaction with "difficult" visits.

PURPOSE: Difficult patients comprise at least 15% of ambulatory visits and are associated with clinician burnout. No structured procedure has been reported to assist health care practitioners with these challenging relationships. This randomized trial evaluated whether a pre- and postvisit patient-centered and clinician-reflective technique called BREATHE OUT improved clinician satisfaction during visits with patients perceived by the clinician as difficult. METHODS: Six family medicine residency clinics paired as urban, suburban, and rural sites were randomized by clinic to the BREATHE OUT intervention or usual care of difficult patients. A total of 57 physician faculty, nurse practitioners, physician assistants, and residents participated. The validated Physician Satisfaction Scale (PSS) was administered and analyzed using hierarchical linear modeling to assess differences between the intervention and control groups. RESULTS: The BREATHE OUT intervention improved the PSS score (P = .02) in the intervention group compared with the usual care group. Female practitioners reported worse PSS scores compared with their male counterparts despite whether they used BREATHE OUT (P = .009). CONCLUSIONS: Application of the BREATHE OUT questionnaire before and after visits improved clinician satisfaction with difficult patient encounters.

Difficult patients: exploring the patient perspective.

BACKGROUND AND OBJECTIVES: Patients experienced as difficult comprise at least 15% of ambulatory visits. To better understand these challenging relationships, we explored the patients' perspectives about their relationships with their doctors. METHODS: Using a cross-sectional study design, we surveyed patients regarding their perception of their doctor-patient relationship using five questions graded on a 7-point Likert scale. Family medicine residents subjectively determined which of their patients were "difficult." This patient "difficulty" status was linked to the patient survey's data through anonymous coding. RESULTS: A total of 161 patients participated, for a response rate of 60%. Of these patients, 20% were perceived as difficult. Two sample t test comparison of means revealed that difficult patients reported greater ease in communication. After adjusting for demographics and individual characteristics, Generalized Linear Model (GLM) uncovered that men reported a harder time talking with their doctor, thought their problems were more challenging, and felt less in control of their health care decisions. Gender was a stronger predictor than perceived difficult status for patients' perceptions of poorer quality relationships with providers. CONCLUSIONS: Surprisingly, difficult patients overall reported greater ease of communication with their residents than non-difficult patients. The pronounced discordance between the perspectives of physicians and patients likely underlies much of the frustration experienced by clinicians. Since difficult patients seem satisfied with the resident-patient relationship, further work is needed to understand this discrepancy and improve physician ease and satisfaction with these challenging relationships.