Clinical and Practice Innovation Improving the Practice of Family Medicine.

Quite a lineup showcasing JABFM's emphasis on research and information for family medicine to improve patients' lives. Articles cover many topics: telemedicine, a clinical decision support tool, control of cardiovascular risk factors, opioid dose reduction, cancer survivorship care, patient engagement with case management/navigation, primary care physician capacity and usual source of care, marketing practices of Medicare Advantage programs, review articles (new diabetes medicine and treatment CHF with reduced ejection fraction), and more.

Research to Improve Clinical Care in Family Medicine: Big Data, Telehealth, Artificial Intelligence, and More.

This issue highlights changes in medical care delivery since the start of the COVID-19 pandemic and features research to advance the delivery of primary care. Several articles report on the effectiveness of telehealth, including its use for hospital follow-up, medication abortion, management of diabetes, and as a potential tool for reducing health disparities. Other articles detail innovations in clinical practice, from the use of artificial intelligence and machine learning to a validated simple risk score that can support outpatient triage decisions for patients with COVID-19. Notably one article reports the impact of a voluntary program using scribes in a large health system on physician documentation behaviors and performance. One article addresses the wage gap between early-career female and male family physicians. Several articles report on inappropriate testing for common health problems; are you following recommendations for ordering Pulmonary Function Tests, mt-sDNA for colon cancer screening, and HIV testing?

A Focus on Climate Change and How It Impacts Family Medicine.

This issue highlights climate change, its effects on patients, and actions clinicians can take to make a difference for their patients and communities. The issue also includes several reports on current trends in family physician practice patterns and the influence of practice structure. Four articles focus on controlled or illicit substances. Noteworthy among them is the description of an innovative yet simple device that allows patients to safely discard unused opioids. Other research covers adverse childhood experiences (ACEs), smoking cessation programs, and the impact of Medicare reimbursement rates on influenza vaccination.

Lingering Impact of COVID-19, Preventive Care Considerations, and US Health System Challenges.

This issue includes articles on the lingering impact of COVID-19, often negative but occasionally positive, on patients, treatment, practices, and health care personnel. Other articles inform on prevention, such as awareness of lung cancer screening among women undergoing screening mammography; failures on sports preparticipation physicals; advance care planning as prevention; and screening for social risk factors. Another article reports on patient experiences of legal recreational cannabis in Washington State. There is a review of perinatal depression recognition and treatment. Two articles separately identify the difficulties of the congressionally created Medicare Advantage & Pharmaceutical Benefit Managers.

Patient Surgical Outcomes When Surgery Residents Are the Primary Surgeon by Intensity of Surgical Attending Supervision in Veterans Affairs Medical Centers.

Objective: Using health records from the Department of Veterans Affairs (VA), the largest healthcare training platform in the United States, we estimated independent associations between the intensity of attending supervision of surgical residents and 30-day postoperation patient outcomes. Background: Academic leaders do not agree on the level of autonomy from supervision to grant surgery residents to best prepare them to enter independent practice without risking patient outcomes. Methods: Secondary data came from a national, systematic 1:8 sample of n = 862,425 teaching encounters where residents were listed as primary surgeon at 122 VA medical centers from July 1, 2004, through September 30, 2019. Independent associations between whether attendings had scrubbed or not scrubbed on patient 30-day all-cause mortality, complications, and 30-day readmission were estimated using generalized linear-mixed models. Estimates were tested for any residual confounding biases, robustness to different regression models, stability over time, and validated using moderator and secondary factors analyses. Results: After accounting for potential confounding factors, residents supervised by scrubbed attendings in 733,997 nonemergency surgery encounters had fewer deaths within 30 days of the operation by 14.2% [0.3%, 29.9%], fewer case complications by 7.9% [2.0%, 14.0%], and fewer readmissions by 17.5% [11.2%, 24.2%] than had attendings not scrubbed. Over the 15 study years, scrubbed surgery attendings may have averted an estimated 13,700 deaths, 43,600 cases with complications, and 73,800 readmissions. Conclusions: VA policies on attending surgeon supervision have protected patient safety while allowing residents in selected teaching encounters to have limited autonomy from supervision.

Research Addressing the Ongoing Changes in the Practice of Family Medicine.

The articles in this issue are divided into 3 categories: 1) increasing our understanding of people's (patients') behaviors; 2) changing how we practice Family Medicine; and 3) rethinking common clinical problems. These categories include multiple topics: nonprescription antibiotic use, recording electronic smoking/vaping, virtual wellness visits, an electronic pharmacist consult service, documenting social determinants of health, medical-legal partnerships, local professionalism, implications of peripheral neuropathy, harm-reduction informed care, decreasing cardiovascular risk, persistent symptoms, and colonoscopy harm.

Family Medicine Researchers Explore the Social Determinants of Health, COVID-19 Issues, and Cancer Survivor Care.

As usual, this issue of the JABFM contains research as broad as the specialty of family medicine itself. The social determinants of health are again a prominent topic. COVID-19 topics in this issue include over-the-counter supplements as adjunct treatments and the influence of public health safety measures on influenza rates during the pandemic. Two separate reports look at the way cancer survivors interact with primary care and the difficulties encountered. A CERA study describes how departments of family medicine are tackling the challenge of training tomorrow's family physicians in point-of care-ultrasound. Physician workforce studies examine pay inequities and burnout. An impressive number other commonly encountered issues in family medicine are addressed using a wide variety of methods and data sources.

Practical Clinical Topics, Digging Deeper into COVID-19, Social Determinants of Health, and Equity.

As a discipline, we continue to learn lessons from Coronavirus disease 2019 (COVID-19)-lessons for practice, systems, and patient care. This issue also includes articles focused on 2 other topics that attract increasing attention by family physicians. First, articles describe how the social determinants of health impact health and how family physicians can overcome those obstacles with their patients. Patients want assistance from health systems for 1 specific need related to social determinants of their health. Second, we see increasing evidence about opioid prescriptions in primary care. Multiple clinical articles are pertinent to family medicine, such as different implications of an elevated sedimentation rate compared with C-reactive protein, practice facilitation, adolescent vaccination, family physician accuracy with potentially malignant skin lesions, and more.

Keeping Patients at the Center of Family Medicine Scholarship.

In addition to the collection of veterans' health articles, this edition of the journal contains a wide range of family medicine research reports, commentaries, clinical reviews, and scholarly observations. These articles clearly exemplify a key strength of family medicine scholarship: the focus is on our patients. Two articles look at modern care of patients with venous thromboembolic disease-the first on acute management and the second on long-term care. Two other articles explore the role of pharmacists in an interdisciplinary team. A clever use of big databases provides a thought-provoking answer about the long-term health of patients with methicillin-resistant Staphylococcus aureus Three articles give us possible glimpses into the future of family medicine, exploring a potential payment reform model, suggesting an alternative approach to cancer screening guideline development, and considering how family physicians remain relevant in the technology-laden medical world of tomorrow.

Advancing Research Methods for Common Problems in Family Medicine and Family Medicine Practice Management.

Several research groups from multiple institutions provide structure and methods to improve research for family medicine. Colon cancer research includes which common screening test for colon cancer most often results in completed colonoscopy. Authors explore how some cardiovascular preventive medications are overused while others are underused. Three research papers specifically advance improvements for practice management, 3 articles address diabetes, 3 others cover family physicians caring for specific populations (pregnant women, children, and those with sports-related issues). There are practical research articles on practice management and others on common clinical problems. This issue also includes a clinical review on acute sensorineural hearing loss and human papilloma virus immunization guidelines that can cause confusion.

Must-Read Family Medicine Research-Glucosamine/Chondroitin Supplements and Mortality, Telomere Length and the Doctor-Patient Relationship, Reducing Opioid Use, and More.

This issue of the Journal contains some exceptional research articles. A few are truly "must-reads," including a fascinating look at the relationship between having a usual source of care and telomere length. Glucosamine/chrondroitin supplementation seems to be helpful for more than just arthritis pain. There is a very practical advice on keeping patients discharged from the emergency department out of the hospital and on reducing patient requests for inappropriate antibiotics. This issue also features 5 articles addressing how family physicians can combat the opioid epidemic. Three articles highlight research on diabetes and another 3 on breast cancer. Payment reform, dermoscopy, and telemedicine are among many other topics covered.

Practical Family Medicine: After-Hours Video Telehealth, Office Procedures, Polyp Follow-up in Older Patients, Terminology for Domestic Violence Intervention.

This issue primarily contains practice-based research reports. For a commentary on these articles, see Tapp.1 JABFM also has a call for submissions and accepted pre-print articles specifically on COVID at our Web site, www.jabfm.org These online COVID-related articles will be collated into a future print issue. This issue also has additional articles, encompassing a range of issues, as is common for JABFM.

Well-Being, New Technologies, and Clinical Evidence for Family Physicians.

This special issue contains several articles on well-being. Not surprisingly, many of these articles are specifically about burnout. The evidence shows differences in the rates of burnout between men and women family physicians as well as their responses. Clinical team structure and organizational change also contribute to burnout. What about the electronic medical record? We are also reminded that burnout is an international issue. There are also several articles on how technology is changing the way family physicians practice. Two articles report on issues regarding screening for frequently seen clinical entities, specifically breast cancer and alcohol misuse. There are also articles looking at the cost of medical assistant turnover in practices, the impact of continuity with a provider on the retention of patients in clinical trials, and much more of interest to family physicians.

New Research on Back Pain, Diet and Diabetes, Advanced Care Planning, and Other Issues Frequently Seen in Family Medicine.

From the United States and Netherlands, we have 2 articles on back pain, with findings that indicate significant treatment differences between the countries, and a high likelihood of persistence. The Inflammatory Diet is now shown to be related to diabetes. Multiple perspectives on palliative care for the homeless. Could pharmacists assist in preventing suicide? There are changes in the practice of family medicine. Social determinants of health substantially influence health and medical care. Moreover, care for patients from deprived communities is under-reimbursed. Patient pre-existing conditions increased after the Affordable Care Act, suggesting that repealing pre-existing condition protections would likely exacerbate disparities in health and health care.

Implementing Practice Changes in Family Medicine to Enhance Care and Prevent Disease Progression.

This issue epitomizes family medicine with a heavy emphasis on research to prevent illness and illness progression. Which patients will experience significant symptomatic knee osteoarthritis? Do the elderly use retail clinics, and what is the impact on care for chronic conditions? Does capitation payment enhance or decrease same-day access? How do primary care practices risk stratify to provide integrated care? Can risk screening and on-site providers enhance psychiatric care? What screening questions should we ask adolescents, to identify problematic drug use? A report on a practice intervention to improve opioid prescribing practices, and another on the significant level of depression in many patients taking opioid medications. Which works better for smoking cessation-e-cigarettes or nicotine gum? Reminders about teratogenic drugs and those that cause hyperpigmentation. Interdisciplinary care with pharmacists in the office does not help just the patients. We have several articles on diabetes-early diagnosis, and consideration of screening for prediabetes as a quality standard-with added commentaries about this possibility.

Family Medicine: Data Driven Practice with Emphasis on Underserved Patients.

Family physicians' role and interest in caring for underserved or undertreated patients is quite evident in this issue of JABFM. One in 5 family physicians provide urgent or emergency care, which is particularly important in rural areas. Methods and resources for obtaining information about social determinants of health are variable. A data-rich article considers how family medicine practice ownership might be associated with quality outcomes. We have articles on using text messages to increase HIV testing and colon cancer screening for Latino patients. For patients with significant behavioral health disorders, 1 article considers early posthospital follow-up to prevent readmission and another notes differences between the views of generalist physicians and psychiatrists on which specialty should test and manage antipsychotic-related metabolic disorders. Five articles provide topic-specific perspectives for diagnosis of systolic heart failure with preserved systolic function, primary care outpatient radiographs, polypharmacy in the elderly with dementia, supporting patients in self-management, and patient and family physician challenges in opioid prescribing. Furthermore, what happened to total opioid prescriptions when 1 version of opioid medication became more difficult to prescribe? Two articles provide treatment information for hepatitis C and initiation of basal insulin for diabetes.

Multiple Research Methodologies Can Advance the Science of Family Medicine.

This issue of the Journal evidences the wide variety of research methods that can effectively answer questions important to the practice of family medicine. For example, this issue includes 4 highly informative reports from qualitative or mix-methods research, plus surveys, a meta-analysis, a case report, and more. Mixed-methods were used to look at practice changes and to compare advance directive tools. Surveys were used to identify practical, but addressable, issues for mailed colon cancer screening tests, and the prevalence of atopic dermatitis, and emollient use in young children. Secondary analyses of national surveys were used to identify low-value patient requests, and how diabetes and prediabetes are being treated. Retrospective chart analysis of patients with frequent hospital admissions identified important characteristics of the patients and their problems. Meta-analysis methodology was used to stratify risks for pneumonia. And, a randomized trial was used to compare ways to train patients to use medical record patient portals.

The Potpourri of Family Medicine, in Sickness and in Health.

Some aspects of the health of Americans are declining, and family medicine is addressing these ailments. Obesity is one factor, and family physicians provide nutrition counseling. Despite new models such as direct primary care, we have not found an ideal method for providing primary care to everyone in our health system. Not all family physicians report burnout: what is their secret? Scribes: some positives and negatives from one group. Rural America is in need of more family physicians who provide prenatal and natal care, and the proof is in the infant mortality rate. We also have 2 articles on improving pediatric care, and research on the relationship of thrush to mode of infant delivery. We have reviews of new cancer and cholesterol drugs, raising awareness of important knowledge for the primary care clinicians seeing the patients who take these drugs. In addition: tick bites and delayed anaphylaxis-when and how, culture-related skin findings, and helping male perpetrators of domestic violence.

Multiple Practical Facts and Ideas to Improve Family Medicine Care.

Seconds count in a study on the best electronic health note format to reduce medical record charting time and increase accuracy. Directly observed family physician work is compared with Current Procedural Terminology (CPT) coding examples and notably under-recognized. This issue contains articles from single practices that that implemented new methods of care and other reports on practice innovations that can be more broadly implemented. We have articles on opioid medication use for acute low back pain in primary care, an electronic chronic pain consult service, a key question to identify potential opioid misuse risk, and newly implemented screening for other substances of abuse. Omissions (or gaps) in care are also highlighted: from the common types of omissions identified by primary care clinicians, self-reported low levels of substance use screening by family medicine prenatal care providers, and inadequate and inadequately available hospital discharge summaries. In addition, the most important alarm symptoms for a cancer diagnosis are reported.

In This Issue: Opiates, Tobacco, Social Determinants of Health, Social Accountability for Non-Profit Hospitals, More on PCMH, and Clinical Topics.

This issue contains several articles about the factors contributing to the complex and deadly interplay between social determinants of health, pain, mental illness, and addictive substances such as opioids and tobacco. One article clearly is a call to action: more than half of opioid prescriptions in the United States are given to patients with mental health problems. Two articles report work on the next steps for social determinants of health in health care settings. Social accountability based on community health needs assessments required of community hospitals should lead to the creation of more family medicine residency positions. Patient-centered medical home (PCMH) recognition can be costly. A new typology for PCMHs is proposed. Other topics include group advance care planning visits, the interaction of dental and primary care, free clinics, a fix for a squeaking wrist, adherence to latent tuberculosis treatment, and more.