Storylines of family medicine V: ways of thinking-honing the therapeutic self.

Storylines of Family Medicine is a 12-part series of thematically linked 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 'V: ways of thinking-honing the therapeutic self', authors present the following sections: 'Reflective practice in action', 'The doctor as drug-Balint groups', 'Cultivating compassion', 'Towards a humanistic approach to doctoring', 'Intimacy in family medicine', 'The many faces of suffering', 'Transcending suffering' and 'The power of listening to stories.' May readers feel a deeper sense of their own therapeutic agency by reflecting on these essays.

Development of a mentor training curriculum to support LGBTQIA+ health professionals.

While mentors can learn general strategies for effective mentoring, existing mentorship curricula do not comprehensively address how to support marginalized mentees, including LGBTQIA+ mentees. After identifying best mentoring practices and existing evidence-based curricula, we adapted these to create the Harvard Sexual and Gender Minority Health Mentoring Program. The primary goal was to address the needs of underrepresented health professionals in two overlapping groups: (1) LGBTQIA+ mentees and (2) any mentees focused on LGBTQIA+ health. An inaugural cohort (N = 12) of early-, mid-, and late-career faculty piloted this curriculum in spring 2022 during six 90-minute sessions. We evaluated the program using confidential surveys after each session and at the program's conclusion as well as with focus groups. Faculty were highly satisfied with the program and reported skill gains and behavioral changes. Our findings suggest this novel curriculum can effectively prepare mentors to support mentees with identities different from their own; the whole curriculum, or parts, could be integrated into other trainings to enhance inclusive mentoring. Our adaptations are also a model for how mentorship curricula can be tailored to a particular focus (i.e., LGBTQIA+ health). Ideally, such mentor trainings can help create more inclusive environments throughout academic medicine.

Pilot test of Consensus Reporting Items for Studies in Primary care (CRISP).

The Consensus Reporting Items for Studies in Primary care (CRISP) provides a new research reporting guideline to meet the needs of the producers and users of primary care (PC) research. Developed through an iterative program of research, including investigators, practicing clinicians, patients, community representatives, and educators, the CRISP Checklist guides PC researchers across the spectrum of research methods, study designs, and topics. This pilot test included a variety of team members using the CRISP Checklist for writing, revising, and reviewing PC research reports. All or most of the 15 participants reported that the checklist was easy to use, improved research reports, and should be recommended by PC research journals. The checklist is adaptable to different study types; not all items apply to all reports. The CRISP Checklist can help meet the needs of PC research when used in parallel with existing guidelines that focus on specific methods and limited topics.

Improving the Reporting of Primary Care Research: Consensus Reporting Items for Studies in Primary Care-the CRISP Statement.

Primary care (PC) is a unique clinical specialty and research discipline with its own perspectives and methods. Research in this field uses varied research methods and study designs to investigate myriad topics. The diversity of PC presents challenges for reporting, and despite the proliferation of reporting guidelines, none focuses specifically on the needs of PC. The Consensus Reporting Items for Studies in Primary Care (CRISP) Checklist guides reporting of PC research to include the information needed by the diverse PC community, including practitioners, patients, and communities. CRISP complements current guidelines to enhance the reporting, dissemination, and application of PC research findings and results. Prior CRISP studies documented opportunities to improve research reporting in this field. Our surveys of the international, interdisciplinary, and interprofessional PC community identified essential items to include in PC research reports. A 2-round Delphi study identified a consensus list of items considered necessary. The CRISP Checklist contains 24 items that describe the research team, patients, study participants, health conditions, clinical encounters, care teams, interventions, study measures, settings of care, and implementation of findings/results in PC. Not every item applies to every study design or topic. The CRISP guidelines inform the design and reporting of (1) studies done by PC researchers, (2) studies done by other investigators in PC populations and settings, and (3) studies intended for application in PC practice. Improved reporting of the context of the clinical services and the process of research is critical to interpreting study findings/results and applying them to diverse populations and varied settings in PC.Annals "Online First" article.

Primary Care Research: Looking Back and Moving Forward With Reflections on NAPCRG's First 50 Years.

NAPCRG celebrated 50 years of leadership and service at its 2022 meeting. A varied team of primary care investigators, clinicians, learners, patients, and community members reflected on the organization's past, present, and future. Started in 1972 by a small group of general practice researchers in the United States, Canada, and the United Kingdom, NAPCRG has evolved into an international, interprofessional, interdisciplinary, and intergenerational group devoted to improving health and health care through primary care research. NAPCRG provides a nurturing home to researchers and teams working in partnership with individuals, families, and communities. The organization builds upon enduring values to create partnerships, advance research methods, and nurture a community of contributors. NAPCRG has made foundational contributions, including identifying the need for primary care research to inform primary care practice, practice-based research networks, qualitative and mixed-methods research, community-based participatory research, patient safety, practice transformation, and partnerships with patients and communities. Landmark documents have helped define classification systems for primary care, responsible research with communities, the central role of primary care in health care systems, opportunities to revitalize generalist practice, and shared strategies to build the future of family medicine. The future of health and health care depends upon strengthening primary care and primary care research with stronger support, infrastructure, training, and workforce. New technologies offer opportunities to advance research, enhance care, and improve outcomes. Stronger partnerships can empower primary care research with patients and communities and increase commitments to diversity and quality care for all. NAPCRG offers a home for all partners in this work.

A pilot clinical skills coaching program to reimagine remediation: a cohort study.

Background New approaches are needed to improve and destigmatize remediation in undergraduate medical education (UME).  The COVID-19 pandemic magnified the need to support struggling learners to ensure competency and readiness for graduate medical education (GME).  Clinical skills (CS) coaching is an underutilized approach that may mitigate the stigma of remedial learning. Methods A six-month CS coaching pilot was conducted at Harvard Medical School (HMS) as a destigmatized remedial learning environment for clerkship and post-clerkship students identified as 'at risk' based on objective structured clinical examinations (OSCE).  The pilot entailed individual and group coaching with five faculty, direct bedside observation of CS, and standardized patient encounters with video review. Strengths-based coaching principles and appreciative inquiry were emphasized.  Results Twenty-three students participated in the pilot: 14 clerkship students (cohort 1) and 9 post-clerkship students (cohort 2).  All clerkship students (cohort 1) demonstrated sustained improvement in CS across three OSCEs compared to baseline: at pilot close, at 6-months post pilot, and at 21-24 months post-pilot all currently graduating students (10/10, 100%) passed the summative OSCE, an HMS graduation requirement. All post-clerkship students (cohort 2) passed the HMS graduation OSCE (9/9,100%). Feedback survey results included clerkship students (9/14; 64%) and post-clerkship students (7/9; 78%); all respondents unanimously agreed that individual coaching was "impactful to my clinical learning and practice". Faculty and leadership fully supported the pilot as a destigmatized and effective approach to remediation.  Conclusion Remediation has an essential and growing role in medical schools.  CS coaching for remedial learning can reduce stigma, foster a growth mindset, and support sustained progress for 'at risk' early clerkship through final year students. An "implementation template" with suggested tools and timelines can be locally adapted to guide CS coaching for UME remediation. The CS coaching pilot model is feasible and can be generalized to many UME programs.

A Comprehensive Clinical Model of Suffering.

Suffering is often a part of the illness experience, and relieving it is a fundamental obligation of medicine. Distress, injury, disease, and loss generate suffering when they threaten meaning in the patient's personal narrative. Family physicians have exceptional opportunities and responsibilities to manage suffering through long-term continuity relationships, demonstrating empathy, and building trust over time and across problems. We propose a new Comprehensive Clinical Model of Suffering (CCMS) founded on the family medicine approach to whole-patient care. Comprehending that suffering can involve every aspect of a patient's life, the CCMS is constructed on 4 axes and 8 domains that form a "Review of Suffering" to help clinicians recognize and manage patient suffering. Applied to clinical care, the CCMS can guide observation and empathetic questioning. Applied to teaching, it can provide a framework for discussions of complex and challenging patients. Barriers to applying the CCMS in practice include clinician training, time with patients, and competing demands. However, by structuring the clinical assessment of suffering, the CCMS may increase the efficiency and effectiveness of clinical encounters and improve patient care and outcomes. The application of the CCMS to patient care, clinical training, and research will require further evaluation.

Key items for reports of primary care research: an international Delphi study.

OBJECTIVE: Reporting guidelines can improve dissemination and application of findings and help avoid research waste. Recent studies reveal opportunities to improve primary care (PC) reporting. Despite increasing numbers of guidelines, none exists for PC research. This study aims to prioritise candidate reporting items to inform a reporting guideline for PC research. DESIGN: Delphi study conducted by the Consensus Reporting Items for Studies in Primary Care (CRISP) Working Group. SETTING: International online survey. PARTICIPANTS: Interdisciplinary PC researchers and research users. MAIN OUTCOME MEASURES: We drew potential reporting items from literature review and a series of international, interdisciplinary surveys. Using an anonymous, online survey, we asked participants to vote on and whether each candidate item should be included, required or recommended in a PC research reporting guideline. Items advanced to the next Delphi round if they received>50% votes to include. Analysis used descriptive statistics plus synthesis of free-text responses. RESULTS: 98/116 respondents completed round 1 (84% response rate) and 89/98 completed round 2 (91%). Respondents included a variety of healthcare professions, research roles, levels of experience and all five world regions. Round 1 presented 29 potential items, and 25 moved into round 2 after rewording and combining items and adding 2 new items. A majority of round 2 respondents voted to include 23 items (90%-100% for 11 items, 80%-89% for 3 items, 70%-79% for 3 items, 60%-69% for 3 items and 50%-59% for 3 items). CONCLUSION: Our Delphi study identified items to guide the reporting of PC research that has broad endorsement from the community of producers and users of PC research. We will now use these results to inform the final development of the CRISP guidance for reporting PC research.

Interprofessional Primary Care Course Impact on Knowledge, Attitudes, and Careers.

BACKGROUND AND OBJECTIVES: Our innovative, highly rated, interprofessional Primary Care Course (PCC) engaged learners in dentistry, medicine, nursing, physician assistants, pharmacy, public health, and social work. PCC used a low-resource, flexible classroom format, earned 99% high student ratings, and increased PC career plans in 56% of students. This study assessed changes in PC knowledge and attitudes and tracked PC career outcomes over 5 years. METHODS: We conducted before-and-after surveys of PCC students at baseline, 1-year, and 5-year follow-up, using anonymous online surveys. An additional controlled study compared PCC students with similar students from the course waitlist. RESULTS: Surveys yielded responses from 100% (84) at baseline, 81% (68) at 1 year, 57% (48) at 5 years, and 34% (28/83) among waitlist students at year 5. Before-and-after matched pairs analyses documented significant increases at year 1, sustained through year 5, in knowledge of PC training and referral patterns and attitudes toward PC value and role in future US health care. Precourse, 56% of students planned PC careers. At year 5, PCC graduates reported working in PC (74%, 29/39), delivering direct PC patient care (48%, 19/39), and working with underserved communities (74%, 29/39). The PC knowledge and attitudes of waitlist students at year 5 were similar to PCC student baseline scores and were significantly lower at year 5. Only 27% (7/26) of waitlist students reported working in PC at year 5. CONCLUSIONS: PCC was associated with sustained increases in PC knowledge, attitudes, and careers across health professions. This low-resource, flexible format can contribute to building PC knowledge, attitudes, and workforce.

Clinician Use of Primary Care Research Reports.

PURPOSE: To assess how primary care practitioners use reports of general health care (GHC) and primary care (PC) research and how well reports deliver what they need to inform clinical practice. METHODS: International, interprofessional online survey, 2019, of primary care clinicians who see patients at least half time. Respondents used frequency scales to report how often they access both GHC and PC research and how frequently reports meet needs. Free-text short comments recorded comments and suggestions. RESULTS: Survey yielded 252 respondents across 29 nations, 55% (121) women, including 88% (195) physicians, nurses 5% (11), and physician assistants 3% (7). Practitioners read research reports frequently but find they usually fail to meet their needs. For PC research, 33% (77) accessed original reports in academic journals weekly or daily, and 36% found reports meet needs "frequently" or "always." They access reports of GHC research slightly more often but find them somewhat less useful. CONCLUSIONS: PC practitioners access original research in academic journals frequently but find reports meet information needs less than half the time. PC research reflects the unique PC setting and so reporting has distinct focus, needs, and challenges. Practitioners desire improved reporting of study context, interventions, relationships, generalizability, and implementation.

Mapping the literature on primary care research reporting: a scoping review.

BACKGROUND: Despite broad efforts to improve the reporting of biomedical research, no reporting guideline exists for primary care (PC) research. Little is known about current reporting practices or how well reports meet the needs of varied users in PC. OBJECTIVE: To map the published literature on PC research reporting: quality, strengths and weaknesses, recommendations and efforts to improve reporting. METHODS: Scoping review of literature across seven major databases and search engines to identify all articles on PC research reporting published in English, 2000-20. An additional secondary search of references of these 25 articles and consideration of expert panel suggestions. Structured data extraction by multiple reviewers using a predetermined form. RESULTS: Search yielded 2847 unique titles, of which 126 underwent full-text review and 25 met inclusion criteria. Publications included opinion pieces (9), systematic reviews (5), methods articles (2), literature reviews (4), qualitative studies (4) and surveys (1). Studies focussed on a variety of topics and research methods. All publications identified the need for improved reporting and recommended items to include in reports. Most commonly, publications cited the need for more detailed reporting on the context of study interventions, clinical settings and health care systems. Most publications endorsed the use of reporting guidelines and recognized the unique needs of PC research reporting. CONCLUSIONS: Published research and opinion identify unique needs for PC research reports and support new guidance to improve the validity, generalizability and application of study findings.

Doctors and health scientists recognize the need to improve the way they report their research. Despite the key role of primary care (PC) in strong health care systems, none of the many reporting guidelines focuses on PC research. To understand what is known about reporting PC research, we systematically searched all scientific articles published in English 2000­20. We studied the 25 key articles, which dealt with a great variety of patients, populations, medical problems and research methods. These articles identified needs for improvement and suggested items to include or ways to communicate research findings more effectively to the variety of readers who must put new research into practice to improve patient care and community health. These readers­practicing clinicians, researchers, patients, teachers and policymakers­need more practical details to understand the context and setting where the research took place and the patients were treated. Readers need better reporting of context to help them judge how they can apply the new research knowledge in their own practices. This review helped identify items to include and ways to improve research reports that can help develop new guidelines for PC research reports.

Improving the Reporting of Primary Care Research: An International Survey of Researchers.

PURPOSE: To assess opportunities to improve reporting of primary care (PC) research to better meet the needs of its varied users. METHODS: International, interprofessional online survey of PC researchers and users, 2018 to 2019. Respondents used Likert scales to rate frequency of difficulties in interpreting, synthesizing, and applying PC research reports. Free-text short answers were categorized by template analysis to record experiences, concerns, and suggestions. Areas of need were checked across existing reporting guidelines. RESULTS: Survey yielded 255 respondents across 24 nations, including 138 women (54.1%), 169 physicians (60%), 32 scientists (11%), 20 educators (7%), and 18 public health professionals (6%). Overall, 37.4% indicated difficulties using PC research reports "50% or more of the time." The most common problems were synthesizing findings (58%) and assessing generalizability (42%). Difficulty was reported by 49% for qualitative, 46% for mixed methods, and 38% for observational research. Most users wanted richer reporting of theoretical foundation (53.7%); teams, roles, and organization of care (53.4%); and patient involvement in the research process (52.7%). Few reported difficulties with ethics or disclosure of funding or conflicts. Free-text answers described special challenges in reporting PC research: context of clinical care and setting; practical details of interventions; patient-clinician and team relationships; and generalizability, applicability and impact in the great variety of PC settings. Cross-check showed that few current reporting guidelines focus on these needs. CONCLUSIONS: Opportunities exist to improve the reporting of PC research to make it more useful for its many users, suggesting a role for a PC research reporting guideline.

General Practitioners in US Medical Practice Compared With Family Physicians.

PURPOSE: General practitioners (GPs) are part of the US physician workforce, but little is known about who they are, what they do, and how they differ from family physicians (FPs). We describe self-identified GPs and compare them with board-certified FPs. METHODS: Analysis of data on 102,604 Doctor of Medicine and Doctor of Osteopathy physicians in direct patient care in the United States in 2016, who identify themselves as GPs or FPs. The study used linking databases (American Medical Association Masterfile, American Board of Family Medicine [ABFM], Area Health Resource File, Medicare Public Use File) to examine personal, professional, and practice characteristics. RESULTS: Of the physicians identified, 6,661 self-designated as GPs and 95,943 self-designated as FPs. Of the self-designated GPs, 116 had been ABFM certified and were excluded from the study. Of the remaining 102,488 physicians, those who self-designated as GPs but were never ABFM certified constituted the GP group (n = 6,545, 6%). Self-designated FPs that were ABFM certified made up the FP group (n = 79,449, 78%). The remaining self-designated FPs not ABFM certified constituted the uncertified group (n = 16,494, 16%). GPs differed from FPs in every characteristic examined. Compared with FPs, GPs are more likely to be older, male, Doctors of Osteopathy, graduates of non-US medical schools, and have no family medicine residency training. GPs practice location is similar to FPs, but GPs are less likely to participate in Medicare or to work in hospitals. CONCLUSIONS: GPs in the United States are a varied group that differ from FPs. Researchers, educators, and policy makers should not lump GPs together with FPs in data collection, analysis, and reporting.