Using Community-Based System Dynamics to Address Structural Racism in Community Health Improvement.

CONTEXT: Structural racism is a profound determinant of health resulting in pervasive health inequities for people of color. Despite the recognition of structural racism as a complex, dynamic system, we lack a shared vision of the system that would enable identification of solutions for equitable systems transformation. POLICY: Through a public health-led community health improvement planning process, a cross-sector consortium implemented community-based system dynamics to provide a systems science lens to guide efforts to eliminate structural racism. IMPLEMENTATION: In group model building sessions involving diverse stakeholders, community-based system dynamics was used to bring together cross-sector stakeholders to create causal loop diagrams of the system of structural racism. Participants identified potential leverage points for actionable focus to eliminate structural racism. EVALUATION: Causal loop diagrams of structural racism generated through group model building demonstrate complex dynamics in the areas of criminal justice, education and economic opportunity, health and health care, quality of life, racial trauma and healing, and a promising system transformative solution through perspective transformation. DISCUSSION: Community-based system dynamics, employed in the context of local community health improvement planning, engages stakeholders in systems thinking through sharing lived experience to create system maps of structural racism and identify leverage points and transportable solutions that foster health equity. These informal maps serve as the foundation for formal computer simulation models that will guide systemic action on high-yield, community-driven solutions to eliminate structural racism.

Unfinished Business: The Role of Research in Family Medicine.

Although the generation of new knowledge through research is a hallmark of medical specialties, research was a low priority in family practice when it was established in 1969. Today, when a base of knowledge is crucial to the ability to lead health care change, the early relationship between family practice and research continues to influence the specialty. An examination of archival and secondary materials finds that the priority placed on research during family practice's early years was shaped by internal and external factors, including, (1) family physicians' desire to differentiate themselves from the prevailing specialty environment; (2) lack of a clear identity in family practice; (3) the non-laboratory nature of family medicine research; (4) reliance on information from other specialties; and, (5) a focus on establishing an academic presence. The low level of attention given to research during the early years of family practice has had lasting implications, as the specialty seeks to transform practice while continuing to struggle to achieve academic acceptance. A strong culture of generalist knowledge is crucial in assuring family medicine's future and strengthening its ability to improve the health of individuals, families, and communities.

Medical Students' Views of the Future in a Rapidly Changing World.

BACKGROUND AND OBJECTIVES: Physicians have long been considered valued members of a solid US health care system. Significant changes in medical education, health care, and society at-large suggest that current medical students may face a different future. To help guide educators and policy makers, we set out to understand medical students' perceptions of the future of health care and their place in it. METHODS: In year one of a longitudinal study, we conducted in-depth interviews of Case Western Reserve University medical students. A multidisciplinary team performed iterative thematic analyses and sampling until reaching saturation on major themes. RESULTS: Eleven medical student participants described social and health care issues as major influences on their professional futures. Concerns included health care system failings, unsustainable costs, climate change, demographic shifts, disinformation, and public distrust in health care. Students looked forward to team practice and using technology, data, and artificial intelligence in care delivery. They hoped for greater access and equity in health care, with a focus on prevention and social, behavioral, and environmental drivers of health. Most students expected to be employed rather than in private practice and sought time/flexibility for professional and personal interests. Paying off medical school debt and advocating for patients and change were priorities. Many saw primary care as important, but fewer envisioned it as their career path of choice. CONCLUSIONS: Medical students envision a future shaped by health care systems and social issues. These findings can inform those helping students prepare for uncertainty and rapid change in their careers, their lives, and the lives of their patients.

The Time Is Now: A Plan to Redesign Family Medicine Residency Education.

A new graduate medical education program in family medicine is urgently needed now. We propose an innovative plan to develop community-based, community-owned family medicine residency programs. The plan is founded on five guiding principles in which residencies will (1) transition to independent, community-owned organizations; (2) sustain comprehensiveness and generalism; (3) emphasize collaborative learning and interprofessional education; (4) develop local educators with national guidance; and (5) share resources, responsibilities, and learning. We describe actionable steps to begin the process of transforming residencies and strengthening primary care. As community-based and locally-run organizations, residencies will gain self-determination in how time is allocated, budgets are spent, and teams function. Building on the momentum of the National Academy of Medicine's 2021 primary care implementation plan and recommendations by family medicine organization leaders, we propose a Decade of Family Medicine Residency Transformation. We encourage individuals and organizations spanning disciplines, health care systems, and communities, to join forces to reimagine and recreate the preparation of outstanding personal physicians dedicated to individual and community health and well-being.

Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond.

The Coronavirus disease 2019 (COVID-19) pandemic has laid bare the dis-integrated health care system in the United States. Decades of inattention and dwindling support for public health, coupled with declining access to primary care medical services have left many vulnerable communities without adequate COVID-19 response and recovery capacity. "Health is a Community Affair" is a 1966 effort to build and deploy local communities of solution that align public health, primary care, and community organizations to identify health care problem sheds, and activate local asset sheds. After decades of independent effort, the COVID-19 pandemic offers an opportunity to reunite and align the shared goals of public health and primary care. Imagine how different things might look if we had widely implemented the recommendations from the 1966 report? The ideas and concepts laid out in "Health is a Community Affair" still offer a COVID-19 response and recovery approach. By bringing public health and primary care together in community now, a future that includes a shared vision and combined effort may emerge.

New knowledge for and about primary care: a view through the looking glass of the Annals of Family Medicine.

PURPOSE: At this second anniversary of the Annals of Family Medicine, we sought to characterize primary care research and to identify opportunities for new directions by analyzing the content of the first and second volumes of the Annals. METHODS: Using an a priori classification scheme, 2 editors independently categorized each research article and essay published in 2003 and 2004, excluding supplements. We categorized the domain of knowledge, methods, topical content, whether articles represented core values of primary care, and looked for articles that studied health/illness/symptoms from a uniquely primary care experience. We reconciled differences by discussion. RESULTS: Among 110 articles, knowledge domains reflected the 4 quadrants of the clinician (n = 6), patient, family, or community (10), health care system (32), disease (22), or the interface (39) between these quadrants. The most frequent methods were cross-sectional studies (23), cohorts (15), randomized clinical trials (13), qualitative interviews (11), analyses of secondary data (11), systematic reviews (11), methods/theory development (10), self-reflections (8), and mixed methods (5). The most common topical areas were chronic disease and prevention. Core primary care values were represented in 75% of articles. Only 2 articles represented an integrative illness/healing perspective. CONCLUSIONS: Despite contemporary forces driving a reductionistic approach, primary care research, as reflected by articles published in the Annals of Family Medicine, addresses the domains of knowledge that contribute to comprehensive, relationship-centered health care. More work is needed to understand the nature of health and illness in whole people and ways to integrate diverse knowledge, methods and fragmented health care.

Physician and staff turnover in community primary care practice.

The effect of a rapidly changing healthcare system on personnel turnover in community family practices has not been analyzed. We describe physician and staff turnover and examine its association with practice characteristics and patient outcomes. A cross-sectional evaluation of length of employment of 150 physicians and 762 staff in 77 community family practices in northeast Ohio was conducted. Research nurses collected data using practice genograms, key informant interviews, staff lists, practice environment checklists, medical record reviews, and patient questionnaires. The association of physician and staff turnover with practice characteristics, patient satisfaction, and preventive service data was tested. During a 2-year period, practices averaged a 53% turnover rate of staff. The mean length of duration of work at the current practice location was 9.1 years for physicians and 4.1 years for staff. Longevity varied by position, with a mean of 3.4 years for business employees, 4.0 years for clinical employees, and 7.8 years for office managers. Network-affiliated practices experienced higher turnover than did independent practices. Physician longevity was associated with a practice focus on managing chronic illness, keeping on schedule, and responding to insurers' requests. No association was found between turnover and patient satisfaction or preventive service delivery rates. Personnel turnover is pervasive in community primary care practices and is associated with employee role, practice network affiliation, and practice focus. The potentially disruptive effect of personnel turnover on practice functioning, finances, and longitudinal relationships with patients deserves further study despite the reassuring lack of association with patient satisfaction and preventive service delivery rates.

The anatomy of asthma care visits in community family practice.

BACKGROUND: We know little about the activities that occur during asthma-related visits with primary care physicians. A better understanding of how time is spent during visits for asthma may facilitate the design of programs to enhance asthma disease management. OBJECTIVE: To describe the content of asthma visits made to family physicians. METHODS: Research nurses directly observed consecutive outpatient visits during two separate days in the offices of 138 community family physicians. Time was classified into 20 different behavioral categories using the Davis Observation Code, and compared for visits for asthma, visits for other chronic conditions, and visits for non-asthma-related acute illnesses during 3035 visits by patients of all ages. RESULTS: Visits for asthma shared several characteristics with visits for other chronic conditions but were longer than visits for other chronic illnesses or for acute illness. Asthma visits were distinguished from both acute care and other chronic care visits by a greater percentage of time spent discussing patient compliance, evaluating patient knowledge, and providing smoking assessment and cessation advice. CONCLUSIONS: Visits for asthma are structured differently than acute care visits and specifically address issues important to asthma self-management. Future quality improvement initiatives should recognize, affirm, and enhance many current behaviors by family physicians, while working to expand specific areas of care that still fall short of asthma care guidelines.