The Gender Wage Gap Among Early-Career Family Physicians.

PURPOSE: Numerous studies have documented salary differences between male and female physicians. For many specialties, this wage gap has been explored by controlling for measurable factors that influence pay such as productivity, work-life balance, and practice patterns. In family medicine where practice activities differ widely between physicians, it is important to understand what measurable factors may be contributing to the gender wage gap, so that employers and policymakers and can address unjust disparities. METHODS: We used data from the 2017 to 2020 American Board of Family Medicine (ABFM) National Graduate Survey (NGS) which is administered to family physicians 3 years after residency (n = 8608; response rate = 63.9%, 56.2% female). The survey collects clinical income and practice patterns. Multiple linear regression analysis was performed, which included variables on hours worked, degree type, principal professional activity, rural/urban, and region. RESULTS: Although early-career family physician incomes averaged $225,278, female respondents reported incomes that were $43,566 (17%) lower than those of male respondents (P = .001). Generally, female respondents tended toward lower-earning principal professional activities and US regions; worked fewer hours (2.9 per week); and tended to work more frequently in urban settings. However, in adjusted models, this gap in income only fell to $31,804 (13% lower than male respondents, P = .001). CONCLUSION: Even after controlling for measurable factors such as hours worked, degree type, principal professional activity, population density, and region, a significant wage gap persists. Interventions should be taken to eliminate gender bias in wage determinations for family physicians.

Physician-Level Continuity of Care and Patient Outcomes in All-Payer Claims Database.

INTRODUCTION: Being one of the few existing measures of primary care functions, physician-level continuity of care (Phy-CoC) is measured by the weighted average of patient continuity scores. Compared with the well-researched patient-level continuity, Phy-CoC is a new instrument with limited evidence from Medicare beneficiaries. This study aimed to expand the patient sample to include patients of all ages and all types of insurance and reassess the associations between full panel-based Phy-CoC scores and patient outcomes. METHODS: Cross-sectional analysis at patient-level using Virginia All-Payer Claims Database (VA-APCD). Phy-CoC scores were calculated by averaging patient's Bice-Boxerman Index scores and weighted by the total number of visits. Patient outcomes included total cost and preventable hospitalization. RESULTS: In a sample of 1.6 million Virginians, patients who lived in rural areas or had Medicare as primary insurance were more likely to be attributed to physicians with the highest Phy-CoC scores. Across all adult patient populations, we found that being attributed to physicians with higher Phy-CoC was associated with 7%-11.8% higher total costs, but was not associated with the odds of preventable hospitalization. Results from models with interactions revealed nuanced associations between Phy-CoC and total cost with patient's age and comorbidity, insurance payer, and the specialty of their physician. CONCLUSIONS: In this comprehensive examination of Phy-CoC using all populations from the VA-APCD, we found an overall positive association of higher full panel-based Phy-CoC with total cost, but a non-significant association with the risk of preventable hospitalization. Achieving higher full panel-based Phy-CoC may have unintended cost implications.

Addressing Social Determinants of Health in Family Medicine Practices.

Primary care practices are under pressure to address patients' social determinants of health (SDOH). However, the extent to which these practices have this ability remains unknown. The objective of this study was to examine the association between physician, practice, and community characteristics and the ability of family medicine practices to address patients' SDOH. This cross-sectional study used data from the American Board of Family Medicine Continuing Certification Questionnaire from 2017 to 2019, with a 100% response rate. Respondents rated their practice's ability to address SDOH, which was dichotomized as high or low. Sequential multivariate logistic regression determined the association of the reported ability to address SDOH with physician, practice, and community characteristics. Among 19,300 respondents, 55.6% reported a high ability to address patients' SDOH. Across models controlling for different groups of variables, characteristics persistently positively associated with ability to address SDOH included employment at a federally qualified health center (Odds Ratios [OR] = 2.111-3.012), federally funded clinic (OR = 1.999-2.897), managed care organization (OR = 2.038-2.303), and working collaboratively with a social worker (OR = 2.000-2.523) or care coordinator (OR = 1.482-1.681). Characteristics persistently negatively associated with the ability to address SDOH were practicing at an independently owned (OR = 0.726-0.812) or small practice (OR = 0.512-0.863). While results varied across models, these findings are important for developing evidence-based policies and recommendations for resource sharing and allocation in clinics and communities. Ensuring availability and access to allied health professionals and community resources may be key components in Family Medicine clinics addressing SDOH.

Growing a rural family physician workforce: The contributions of rural background and rural place of residency training.

OBJECTIVE: To determine the distinct influences of rural background and rural residency training on rural practice choice among family physicians. DATA SOURCES AND STUDY SETTING: We used a subset of The RTT Collaborative rural residency list and longitudinal data on family physicians from the American Board of Family Medicine National Graduate Survey (NGS; three cohorts, 2016-2018) and American Medical College Application Service (AMCAS). STUDY DESIGN: We conducted a logistic regression, computing predictive marginals to assess associations of background and residency location with physician practice location 3 years post-residency. DATA COLLECTION/EXTRACTION METHODS: We merged NGS data with residency type-rural or urban-and practice location with AMCAS data on rural background. PRINCIPAL FINDINGS: Family physicians from a rural background were more likely to choose rural practice (39.2%, 95% CI = 35.8, 42.5) than those from an urban background (13.8%, 95% CI = 12.5, 15.0); 50.9% (95% CI = 43.0, 58.8) of trainees in rural residencies chose rural practice, compared with 18.0% (95% CI = 16.8, 19.2) of urban trainees. CONCLUSIONS: Increasing rural programs for training residents from both rural and urban backgrounds, as well as recruiting more rural students to medical education, could increase the number of rural family physicians.

Impact of Service-Based Student Loan Repayment Program on the Primary Care Workforce.

PURPOSE: As the average level of medical education indebtedness rises, physicians look to programs such as Public Service Loan Forgiveness (PSLF) and National Health Service Corps (NHSC) to manage debt burden. Both represent service-dependent loan repayment programs, but the requirements and program outcomes diverge, and assessing the relative uptake of each program may help to inform health workforce policy decisions. We sought to describe variation in the composition of repayment program participant groups and measure relative impact on patient access to care. METHODS: In this bivariate analysis, we analyzed data from 10,677 respondents to the American Board of Family Medicine's National Graduate Survey to study differences in loan repayment program uptake as well as the unique participant demographics, scope of practice, and likelihood of practicing with a medically underserved or rural population in each program cohort. RESULTS: The rate of PSLF uptake tripled between 2016 and 2020, from 7% to 22% of early career family physicians, while NHSC uptake remained static at 4% to 5%. Family physicians reporting NHSC assistance were more likely than those reporting PSLF assistance to come from underrepresented groups, demonstrated a broader scope of practice, and were more likely to practice in rural areas (23.3% vs 10.8%) or whole-county Health Professional Shortage Areas (12.5% vs 3.7%) and with medically underserved populations (82.2% vs 24.2%). CONCLUSIONS: Although PSLF supports family physicians intending to work in public service, their peers who choose NHSC are much more likely to work in underserved settings. Our findings may prompt a review of the goals of service loan forgiveness programs with potential to better serve health workforce needs.

Colorectal Cancer Screening in Rural and Urban Primary Care Practices Amid Implementation of the Medicare Access and CHIP Reauthorization Act.

PURPOSE: The Medicare Access and CHIP Reauthorization Act (MACRA) incentivized primary care practices to improve colorectal cancer screening rates. This study examined if colorectal screening rates improved among rural and urban primary care practices amid implementation of MACRA. METHODS: Colorectal cancer screening data are from a national registry of 139 primary care practices. Repeated measures regression tested for rural/urban differences and changes in screening rates between 2016 and 2020, adjusting for county demographic factors and social deprivation. RESULTS: Screening rates were 64% in both rural and urban practices in the first quarter of 2016 and increased to 80% and 83% in rural and urban practices, respectively, in the last quarter of 2020. In adjusted analyses, screening rates increased by 4% per year and there were no rural/urban differences. Lower screening rates were associated with higher county proportions of persons who were 45 to 74 years of age and Hispanic. Higher screening rates were associated with higher county proportions of persons who were White, Black, and Asian and higher social deprivation. CONCLUSIONS: Colorectal screening rates improved among rural and urban primary care practices during implementation of MACRA, but disparities persist among practices serving county populations that are relatively older, more Hispanic, and have higher social deprivation.

Relationship Between Physician Burnout And The Quality And Cost Of Care For Medicare Beneficiaries Is Complex.

Despite reports of a physician burnout epidemic, there is little research on the relationship between burnout and objective measures of care outcomes and no research on the relationship between burnout and costs of care. Linking survey data from 1,064 family physicians to Medicare claims, we found no consistent statistically significant relationship between seven categories of self-reported burnout and measures of ambulatory care-sensitive admissions, ambulatory care-sensitive emergency department visits, readmissions, or costs. The coefficients for ambulatory care-sensitive admissions and readmissions for all burnout levels, compared with never being burned out, were consistently negative (fewer ambulatory care-sensitive admissions and readmissions), suggesting that, counterintuitively, physicians who report burnout may nevertheless be able to create better outcomes for their patients. Even if true, this hypothesis should not indicate that physician burnout is beneficial or that efforts to reduce physician burnout are unimportant. Our findings suggest that the relationship between burnout and outcomes is complex and requires further investigation.

Family Practices in Transforming Clinical Practice Initiative Showed No Changes in Medicare Costs or Utilization.

BACKGROUND: The Centers for Medicare and Medicaid Services proposed that the Transforming Clinical Practice Initiative (TCPI) would improve health outcomes for patients, reduce utilization of institutional services, and generate significant savings for payers by the end of September 2019. OBJECTIVE: The objective of this study was to investigate whether participation in TCPI's Practice Transformation Networks (PTNs) was associated with improved cost and utilization outcomes for Medicare patients of family medicine-based practices in the first 2 years, that is, 2016-2017, of the Initiative. STUDY DESIGN: A quasi-experimental design with a longitudinal cohort of family medicine-based practices and a propensity-matched comparison sample. SUBJECTS: A total of 761 PTN practices and 3451 non-PTN practices. MEASURES: To measure practice-level patient outcomes, we attributed patients to practice based on the plurality of office visits. We obtained Medicare claims from 2011 to 2017 to assess PTN participation effects for Medicare Part A and B costs, hospital admission, and emergency department visit rates using a Difference-in-Differences design, adjusting for baseline characteristics. RESULTS: The differences in Medicare Part A and B costs (-1.71%, P=0.25), annual rates of hospitalization (-0.59%, P=0.12) and emergency department visit (-0.29%, P=0.46) were not significantly lower among PTN practices (N=761) than among propensity score-matched non-PTN practices (N=3541). CONCLUSIONS: TCPI's transforming efforts, such as the outcomes examined in the study, might need a longer time frame to manifest and require evaluation after the full 4-year participation period. The indistinguishable effect of PTN participation may also be attributed to the fact that non-PTN practices might have participated in other initiatives that changed their care and curbed health care utilization and costs consequently.

Practice Patterns of Family Physicians With and Without Addiction Medicine Board Certification.

BACKGROUND: The American Board of Medical Specialties recognized addiction medicine (ADM) as a subspecialty in 2016, which was timely given the recent rise in substance use disorder (SUD). The impact of this dual board opportunity on Family Medicine has not been described. Our study enumerates and characterizes physicians dually certified in Family Medicine and ADM. METHODS: We linked American Board of Medical Specialties data from March 2020 on physicians dually boarded in Family Medicine and ADM to responses on demographic and scope of practice questions in the American Board of Family Medicine (ABFM) National Graduate Survey and Family Medicine Certification Examination Registration Questionnaire. RESULTS: Of current ABFM Diplomates, 0.53% (492/93,269) are also boarded in ADM. Based on survey responses from a subset of dually certified physicians, those who are dually certified are more likely to practice in federally qualified health centers and to hold a faculty position. Dually certified physicians are more likely to provide HIV/AIDS and hepatitis C management and are as likely as non-dually certified physicians to provide newborn care, obstetric deliveries, inpatient adult medicine care, and intensive care. DISCUSSION: While only a small proportion of family physicians carry dual ADM board certification, those that do disproportionately serve vulnerable populations while retaining broad scope of care. Further work is needed to examine whether SUD treatment access could be addressed by implementing models that support dually certified physicians in consultative and educational efforts that would amplify their impact across the primary care workforce.

Does Community- or University-Based Residency Sponsorship Affect Graduate Perceived Preparation or Performance?

BACKGROUND: Residency training occurs in varied settings. Whether there are differences in the training received by graduates of community- or medical school-based programs has been the subject of debate. OBJECTIVE: This study examined the perceived preparation for practice, scope of practice, and American Board of Family Medicine (ABFM) board examination pass rates of family physicians in relation to the type of residency program (community, medical school, or partnership) in which they trained. METHODS: Predetermined survey responses were abstracted from the 2016 and 2017 National Family Medicine Graduate Survey of ABFM and linked to data about residency programs obtained from the websites of national organizations. Descriptive statistics were used to summarize the data and logistic regression to examine differences between survey results based on type of residency training: community, medical school, or partnership. RESULTS: Differences in the perception of preparation as well as current scope of practice were noted for the 3 residency types. The differences in perception were mainly noted in hospital-based skills, such as intubation and ventilator management, and in women's health and family planning services, with different program types increasing preparedness perception in different domains. CONCLUSIONS: In general, graduates of family medicine community-based, non-affiliated, and partnership programs perceived they were prepared for and were providing more of the services queried in the survey than graduates of medical school-based programs.

Primary Care Practice Finances In The United States Amid The COVID-19 Pandemic.

As a result of the coronavirus disease 2019 (COVID-19) pandemic, virtually all in-person outpatient visits were canceled in many parts of the country between March and May 2020. We sought to estimate the potential impact of COVID-19 on the operating expenses and revenues of primary care practices. Using a microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements, including telemedicine visits, we estimated that over the course of calendar year 2020, primary care practices would be expected to lose 67,774 in gross revenue per full-time-equivalent physician (the difference between 2020 gross revenue with COVID-19 and the anticipated gross revenue if COVID-19 had not occurred). We further estimated that the cost at a national level to neutralize the revenue losses caused by COVID-19 among primary care practices would be $15.1 billion. This could more than double if COVID-19 telemedicine payment policies are not sustained.

Prevalence and Factors Associated with Family Physicians Providing E-Visits.

PURPOSE: The use of telemedicine has grown in recent years. As a subset of telemedicine, e-visits typically involve the evaluation and management of a patient by a physician or other clinician through a Web-based or electronic communication system. The national prevalence of e-visits by primary care physicians is unclear as is what factors influence adoption. The purpose of this study was to examine the prevalence of family physicians providing e-visits and associated factors. METHODS: A national, cross-sectional practice demographic questionnaire for 7580 practicing family physicians was utilized. Bivariate statistics were calculated and logistic regression was conducted examining both physician level and practice level factors associated with offering e-visits. RESULTS: The overall prevalence of offering e-visits was 9.3% (n = 702). Compared with private practice physicians, other physicians were more likely to offer e-visits if their primary practice was an academic health center/faculty practice (odds ratio [OR], 1.73; 95% CI, 1.03 to 2.91), managed care/health maintenance organization (HMO) practice (OR, 9.79; 95% CI, 7.05 to 13.58), hospital-/health system-owned medical practice (not including managed care or HMO) (OR, 2.50; 95% CI, 1.83 to 3.41), workplace clinic (OR, 2.28; 95% CI, 1.43 to 3.63), or federal (military, Veterans Administration [VA]/Department of Defense) (OR, 4.49; 95% CI, 2.93 to 6.89). Physicians with no official ownership stake (OR, 0.44; 95% CI, 0.28 to 0.68) or other ownership arrangement (OR, 0.29; 95% CI, 0.12 to 0.71) had lower odds of offering e-visits compared with sole owners. CONCLUSION: Fewer than 10% of family physicians provided e-visits. Physicians in HMO and VA settings (ie, capitated vs noncapitated models) were more likely to provide e-visits, which suggests that reimbursement may be a major barrier.

Experience of Family Physicians in Practice Transformation Networks.

To help health care practices transition away from fee-for-service reimbursement and toward value-based payment, the Transforming Clinical Practice Initiative was launched in October 2015. It was designed to provide clinicians support through peer-based Practice Transformation Networks (PTNs). A group of American Board of Family Medicine board-certified family physicians enrolled in PTNs described their expectations of and experiences with PTN participation; we analyzed open-text comments. Physicians expected and experienced PTN support in informatics and data, team building, and workflow and care coordination; however, expectations regarding patient care and engagement, costs and payment reform, and population and panel health were described less frequently.

The Current State of Research Capacity in US Family Medicine Departments.

BACKGROUND AND OBJECTIVES: Capacity for conducting family medicine research has grown significantly since the specialty was founded. Many calls to increase this capacity have been published, but there has been no consistent, systematic, and longitudinal assessment. This survey was designed to gather baseline data with an easily replicable set of measures associated with research productivity that can guide and monitor the impact of efforts to build research capacity in US departments of family medicine (DFMs). METHODS: We surveyed family medicine department chairs regarding departmental research capacity using well-established empirical measures of capacity (trained research faculty, infrastructure, research leadership, and funding) and a self-assessment. We used bivariate analyses to assess correlation between the empirical measures and the self-assessed stage of research capacity. RESULTS: Self-assessed capacity was significantly associated with every empirical measure. High-capacity departments have more research-trained faculty, more faculty effort, utilize more research "laboratories," have more faculty serving on federal peer-review panels, more faculty as principal investigators, devote more internal funding to research, and garner larger amounts of funding from more external funding sources than moderate or minimal-capacity departments. CONCLUSIONS: US DFMs have made great strides over the past half century in building research capacity. However, much more capacity in family medicine and primary care research is needed to produce new knowledge necessary to improve the health and health care of the nation. Periodic measurement using the simple, replicable, and valid minimum measures of this study provides an opportunity to establish longitudinal tracking of change in research capacity in US DFMs.

Physician Opinions about American Board of Family Medicine Self-Assessment Modules (2006-2016).

INTRODUCTION: Maintenance of Certification (MOC) was implemented to help physicians remain current with evolving medical standards, but has been criticized for being irrelevant to practice. We assessed family physicians' (FPs') opinions about the content of American Board of Family Medicine (ABFM) self-assessment modules (SAMs). METHODS: We used ABFM administrative data from feedback surveys completed after each of the 16 SAMs from 2006 to 2016. FPs rated agreement with 2 statements-1) "Content is appropriate for my practice," and 2) "Content was presented at an appropriate level"-on a scale of 1 (strongly disagree) to 6 (strongly agree). We calculated mean ratings of each statement by year and stratified by Knowledge Assessment (KA) and Clinical Simulation (CS) portions of the SAM. We plotted mean ratings by FPs' age at their first SAM completion and the total number of SAMs completed. RESULTS: SAMs were completed (n = 633,198) from 2006 to 2016 with 448,408 (71%) feedback surveys completed. The annual mean ratings of both statements varied little (less than 0.5) and were above 4.5 for all SAMs. CS ratings were consistently lower than KA ratings. FPs of all ages at first SAM provided similar ratings and agreement with content appropriateness increased with repeated exposure to SAMs. CONCLUSION: Over 11 years, the content of ABFM SAMs was regarded by FPs as appropriate for practice and presented at an appropriate level. Continued monitoring of feedback is necessary to keep the content of MOC programs relevant for physicians' practice.

Debt and the Emerging Physician Workforce: The Relationship Between Educational Debt and Family Medicine Residents' Practice and Fellowship Intentions.

PURPOSE: Educational debt is increasing and may affect physicians' career choices. High debt may influence family medicine residents' initial practice setting and fellowship training decisions, adversely affecting the distribution of primary care physicians. The purpose of this study was to determine whether debt was associated with graduating family medicine residents' practice and fellowship intentions. METHOD: The authors completed a cross-sectional secondary analysis of 2014 and 2015 American Board of Family Medicine (ABFM) examination registration questionnaire data and ABFM administrative data. They used multivariate logistic regression to determine whether educational debt was associated with graduating residents' practice (ownership and type) and fellowship intentions. RESULTS: Most residents (89.7%; 3,368) intended to pursue an employed position, but this intention was not associated with their debt. Residents with high debt ($150,000-$249,999) had lower odds of intending to work for a government organization (odds ratio [OR] 0.57; confidence interval [CI] 0.41-0.79). Those with high or very high debt (> $250,000) had lower odds of choosing academic practice (OR 0.55, CI 0.36-0.85 and OR 0.62, CI 0.40-0.96, respectively) or a geriatrics fellowship (OR 0.36, CI 0.20-0.67 and OR 0.29, CI 0.15-0.55, respectively). CONCLUSIONS: High educational debt may contribute to national shortages of academic primary care physicians and geriatricians. Existing National Health Service Corps loan repayment opportunities may not offer adequate incentives to primary care physicians with high debt. The medical community should advocate for policies that better align financial incentives with workforce needs.

A qualitative study of trainee experiences in Family Medicine-Obstetrics fellowships.

BACKGROUND: Family Medicine-Obstetrics fellowships provide family physicians with advanced obstetrics training. No accreditation system exists for these fellowships, which leads to variable training. Variation of fellows' experiences is not well understood. Our objective is to understand the motivations, training, and overall experiences of fellows in Family Medicine-Obstetrics fellowships, which may inform opportunities for improvement in fellowship design and suggest how Family Medicine-Obstetrics fellowship-trained physicians are prepared to practice among other obstetrics providers postgraduation. METHODS: We conducted semistructured interviews with current and past Family Medicine-Obstetrics fellows between Spring 2014 and Winter 2015. We used a snowball sampling approach. Interviews were recorded, transcribed, and coded following an inductive approach to content analysis. RESULTS: We contacted 47 and interviewed 21 current and past Family Medicine-Obstetrics fellows from 15 programs from across the country. Fellowships varied in cohort size, length, co-occurring presence of obstetrics and gynecology training programs, and structure and curriculum. Interviewees were motivated to complete a fellowship because of inadequate obstetrics training in residency, or because of an interest in rural or urban underserved practice. Fellowship experiences were shaped by fellowship leadership, program structure and curriculum, and relationships with obstetricians. Some felt prepared to forge collaborative professional relationships with obstetricians. CONCLUSIONS: The diversity of fellows' experiences suggests possible avenues of improvement for Family Medicine-Obstetrics fellowships. These fellowships can prepare physicians to provide obstetric services in a variety of settings, including working in multispecialty integrated maternity care systems.

Higher Primary Care Physician Continuity is Associated With Lower Costs and Hospitalizations.

PURPOSE: Continuity of care is a defining characteristic of primary care associated with lower costs and improved health equity and care quality. However, we lack provider-level measures of primary care continuity amenable to value-based payment, including the Medicare Quality Payment Program (QPP). We created 4 physician-level, claims-based continuity measures and tested their associations with health care expenditures and hospitalizations. METHODS: We used Medicare claims data for 1,448,952 beneficiaries obtaining care from a nationally representative sample of 6,551 primary care physicians to calculate continuity scores by 4 established methods. Patient-level continuity scores attributed to a single physician were averaged to create physician-level scores. We used beneficiary multilevel models, including beneficiary controls, physician characteristics, and practice rurality to estimate associations with total Medicare Part A & B expenditures (allowed charges, logged), and any hospitalization. RESULTS: Our continuity measures were highly correlated (correlation coefficients ranged from 0.86 to 0.99), with greater continuity associated with similar outcomes for each. Adjusted expenditures for beneficiaries cared for by physicians in the highest Bice-Boxerman continuity score quintile were 14.1% lower than for those in the lowest quintile ($8,092 vs $6,958; ß = -0.151; 95% CI, -0.186 to -0.116), and the odds of hospitalization were 16.1% lower between the highest and lowest continuity quintiles (OR = 0.839; 95% CI, 0.787 to 0.893). CONCLUSIONS: All 4 continuity scores tested were significantly associated with lower total expenditures and hospitalization rates. Such indices are potentially useful as QPP measures, and may also serve as proxy resource-use measures, given the strength of association with lower costs and utilization.

Practice Rurality of Family Physicians Enrolled in a Practice Transformation Network.

The Transforming Clinical Practice Initiative prioritized the delivery of free practice transformation assistance by Practice Transformation Networks (PTNs) to small and rural practices that may otherwise lack the resources needed to succeed in Medicare's value-based payment (VBP) programs. We assessed the enrollment of rural practices in PTNs using 2016 TCPI enrollment data and American Board of Family Medicine recertification examination registration data from 2013 to 2016. PTNs enrolled a higher proportion of rural family medicine practices than are represented across the general workforce (P < .0001). We await more comprehensive data releases to fully understand enrollment to this important initiative.

Barriers Faced by Family Medicine Graduates Interested in Performing Obstetric Deliveries.

Fewer family physicians are providing deliveries, which raises concern for access to obstetric care. We found that among recent family medicine graduates who would like to do deliveries, difficulty finding a position that supports including deliveries was a major barrier.